Low immunogenicity corticosteroid compositions

ABSTRACT

Triamcinolone compositions, and methods of using such compositions, useful for injection into the vitreous of human eyes or into a joint are provided. Such compositions can include triamcinolone particles present in a therapeutically effective amount, a viscosity inducing component, and an aqueous carrier component. The compositions have viscosities of at least about 10 cps or about 100 cps at a shear rate of 0.1/second. In a preferred embodiment, the viscosity is in the range of from about 80,000 cps to about 300,000 cps. In a most preferred embodiment, the viscosity is in the range of from about 140,000 cps to about 280,000 cps t a shear rate of 0.1/second at 25° C. The compositions advantageously suspend the triamcinolone particles for prolonged periods of time.

CROSS REFERENCE

This application is a continuation in part of application Ser. No.11/354,415, filed Feb. 14, 2006, which is a continuation in part ofapplication Ser. No. 10/966,764, filed Oct. 14, 2004, which applicationclaims the benefit of provisional patent application Ser. No.60/519,237, filed Nov. 12, 2003 and provisional is patent applicationSer. No. 60/530,062, filed Dec. 16, 2003, all of which applications arehereby incorporated herein by reference in their entireties.

BACKGROUND

The present invention relates to corticosteroid compositions and methodsfor treating and/or preventing ocular conditions, such as anteriorocular conditions and posterior ocular conditions, as well as fortreating various articular pathologies. In particular the presentinvention relates to extended release and sustained releasetriamcinolone compositions, including injectable implants, for treatingposterior ocular conditions, as well as for treating joint inflammationand/or joint pain.

A pharmaceutical composition (synonymously a composition) is aformulation which contains at least one active ingredient (for example acorticosteroid such as a triamcinolone) as well as, for example, one ormore excipients, buffers, carriers, stabilizers, preservatives and/orbulking agents, and is suitable for administration to a patient toachieve a desired effect or result. The pharmaceutical compositionsdisclosed herein can have diagnostic, therapeutic, cosmetic and/orresearch utility in various species, such as for example in humanpatients or subjects.

An ocular condition can include a disease, aliment or condition whichaffects or involves the eye or one of the parts or regions of the eye.Broadly speaking the eye includes the eyeball and the tissues and fluidswhich constitute the eyeball, the periocular muscles (such as theoblique and rectus muscles) and the portion of the optic nerve which iswithin or adjacent to the eyeball. An anterior ocular condition is adisease, ailment or condition which affects or which involves ananterior (i.e. front of the eye) ocular region or site, such as aperiocular muscle, an eye lid or an eye ball tissue or fluid which islocated anterior to the posterior wall of the lens capsule or ciliarymuscles. Thus, an anterior ocular condition primarily affects orinvolves, the conjunctiva, the cornea, the conjunctiva, the anteriorchamber, the iris, the posterior chamber (behind the retina but in frontof the posterior wall of the lens capsule), the lens or the lens capsuleand blood vessels and nerve which vascularize or innervate an anteriorocular region or site. A posterior ocular (also referred to hereinsynonymously as a “posterior segment”) condition is a disease, ailmentor condition which primarily affects or involves a posterior ocularregion or site such as choroid or sclera (in a position posterior to aplane through the posterior wall of the lens capsule), vitreous,vitreous chamber, retina, optic nerve (i.e. the optic disc), and bloodvessels and nerves which vascularize or innervate a posterior ocular (orposterior segment) region or site.

Thus, a posterior ocular condition can include a disease, ailment orcondition, such as for example, macular degeneration (such asnon-exudative age related macular degeneration and exudative age relatedmacular degeneration); choroidal neovascularization; acute macularneuroretinopathy; macular edema (such as cystoid macular edema anddiabetic macular edema); Behcet's disease, retinal disorders, diabeticretinopathy (including proliferative diabetic retinopathy); retinalarterial occlusive disease; central retinal vein occlusion; uveitis(including intermediate and anterior uveitis); retinal detachment;ocular trauma which affects a posterior ocular site or location; aposterior ocular condition caused by or influenced by an ocular lasertreatment; posterior ocular conditions caused by or influenced by aphotodynamic therapy; photocoagulation; radiation retinopathy;epiretinal membrane disorders; branch retinal vein occlusion; anteriorischemic optic neuropathy; non-retinopathy diabetic retinal dysfunction,retinitis pigmentosa and glaucoma. Glaucoma can be considered aposterior ocular condition because a therapeutic goal can be to preventthe loss of or reduce the occurrence of loss of vision due to damage toor loss of retinal cells or optic nerve cells (i.e. neuroprotection).

An anterior ocular condition can include a disease, ailment orcondition, such as for example, aphakia; pseudophakia; astigmatism;blepharospasm; cataract; conjunctival diseases; conjunctivitis; cornealdiseases; corneal ulcer; dry eye syndromes; eyelid diseases; lacrimalapparatus diseases; lacrimal duct obstruction; myopia; presbyopia; pupildisorders; refractive disorders and strabismus. Glaucoma can also beconsidered to be an anterior ocular condition because a clinical goal ofglaucoma treatment can be to reduce a hypertension of aqueous fluid inthe anterior chamber of the eye (i.e. reduce intraocular pressure).

Macular edema is a major cause of visual loss in patients with diabetes,central retinal vein occlusion (CRVO) and branch retinal vein occlusion(BRVO). Although laser photocoagulation can reduce further vision lossin patients with diabetic macular edema (DME), vision that has alreadybeen decreased by macular edema usually does not improve by use of laserphotocoagulation. Currently, there is no FDA (U.S. Food and DrugAdministration) approved treatment for macular edema associated withCRVO. For macular edema associated with BRVO, grid laserphotocoagulation may be an effective treatment for some patients.

Diabetic macular edema results from abnormal leakage of macromolecules,such as lipoproteins, from retinal capillaries into the extravascularspace followed by an oncotic influx of water into the extravascularspace. Abnormalities in the retinal pigment epithelium may also cause orcontribute to diabetic macular edema. These abnormalities can allowincreased fluid from the choriocapillaries to enter the retina or theymay decrease the normal efflux of fluid from the retina to thechoriocapillaries. The mechanism of breakdown of the blood-retinabarrier at the level of the retinal capillaries and the retinal pigmentepithelium may be due to changes to tight junction proteins such asoccludin. Antcliff R., et al Marshall J., The pathogenesis of edema indiabetic maculopathy, Semin Opthalmol 1999; 14:223-232.

Macular edema from venous occlusive disease can result from thrombusformation at the lamina cribrosa or at an arteriovenous crossing. Thesechanges can result in an increase in retinal capillary permeability andaccompanying retinal edema. The increase in retinal capillarypermeability and subsequent retinal edema can ensue from of a breakdownof the blood retina barrier mediated in part by vascular endothelialgrowth factor (VEGF), a 45 kD glycoprotein, as it is known that VEGF canincrease vascular permeability. VEGF may regulate vessel permeability byincreasing phosphorylation of tight junction proteins such as occludinand zonula occluden. Similarly, in human non-ocular disease states suchas ascites, VEGF has been characterized as a potent vascularpermeability factor (VPF).

The normal human retina contains little or no VEGF; however, hypoxiacauses upregulation of VEGF production. Disease states characterized byhypoxia-induced VEGF upregulation include CRVO and BRVO. This hypoxiainduced upregulation of VEGF can be inhibited pharmacologically. Pe'erJ. et al., Vascular endothelial growth factor upregulation in humancentral retinal vein occlusion, Opthalmology 1998; 105:412-416. It hasbeen demonstrated that anti-VEGF antibodies can inhibit VEGF drivencapillary endothelial cell proliferation. Thus, attenuation of theeffects of VEGF introduces a rationale for treatment of macular edemafrom venous occlusive disease.

Corticosteroids, a class of substances with anti-inflammatoryproperties, have been demonstrated to inhibit the expression of the VEGFgene. Nauck M. et al., Induction of vascular endothelial growth factorby platelet-activating factor and platelet-derived growth factor isdownregulated by corticosteroids, Am J Resp Cell Mol Biol 1997;16:398-406. Additionally, corticosteroids can downregulate the inductionof VEGF by the pro-inflammatory mediators PDGF and platelet-activatingfactor (PAF) in a time and dose-dependent manner. Nauck M. et al.,Corticosteroids inhibit the expression of the vascular endothelialgrowth factor gene in human vascular smooth muscle cells, Euro JPharmacol 1998; 341:309-315. Thus, corticosteroids can to down-regulateVEGF production and reduce breakdown of the blood-retinal barrier.Certain steroids can also have antiangiogenic properties possibly due toattenuation of the effects of VEGF. It should be noted that althoughcertain corticosteroids can apparently down regulate VEGF productionthere are a number of other physiological mechanisms by whichcorticosteroids can effect the pathogenesis of an ocular condition, suchas macular edema.

Triamcinolone

Triamcinolone is a corticosteroid and it has been reported that a salinesuspension is of triamcinoline (1 mg triamcinolone acetonide in 0.1 mlsaline) is non-toxic upon intravitreal injection. McCuen B. et al., Thelack of toxicity of intravitreally administered triamcinolone acetonide,Am J Opthalmol 1981; 91:785-788. Intravitreal triamcinolone has beenused to treat proliferative vitreoretinopathy (Jonas J. et al.,Intravitreal injection of crystalline cortisone as adjunctive treatmentof proliferative vitreoretinopathy, Br J Opthalmol 2000; 84:1064-1067),as well as choroidal neovascularization (Challa J. et al., Exudativemacular degeneration and intravitreal triamcinolone: 18 month follow up,Aust N Z J Opthalmol 1998; 26:277-281; Penfold P. et al., Exudativemacular degeneration and intravitreal triamcinolone: A pilot study, AustN Z J Opthalmol 1995; 23:293-298, and; Danis R. et al., Intravitrealtriamcinolone acetonide in exudative age-related macular degeneration,Retina 2000; 20:244-250).

Additionally, European patent application 244 178 A2 (Keller) disclosesintravitreal injection of an aqueous solution of dexamethasone and ahyaluronic acid, and a topical triamcinolone suspension for eartreatment is discussed in Chang H. et al., Development of a topicalsuspension containing three active ingredient, Drug Dev and Ind Pharm,28(1), 29-39 (2002). Einmahl S. et al, Evaluation of a novel biomaterialin the suprachoroidal space of the rabbit eye, Invest Ophthal & V is Sci43(5); 1533-1539 (2002) discusses injection of a poly(ortho ester) intothe suprachoroidal space, and Einmahl S. et al, Therapeutic applicationsof viscous and injectable poly(ortho esters), Adv Drug Del Rev 53 (2001)45-73, discloses that a poly ortho ester polymer containing fluorouracilmarkedly degrades five days after intravitreal administration. See alsoU.S. Pat. No. 5,770,589 (Billson) which discusses intravitreal injectionof a corticosteroid, such as triamcinolone acetonide. U.S. Pat. No.5,209,926 (Babcock) discusses ophthalmic use of various aminosubstituted steroids.

Known formulations of triamcinolone clear (diffuses out of and/or isremoved by one or more active transport mechanisms) from the vitreouswithin at most about 90 days, although it has been speculated that witha known formulation (Kenalog) the triamcinolone may be detectable in thevitreous for no more than four months after intravitreal injection.Thus, McCuen B. et al. (1981) supra at page 786 noted that after threemonths no triamcinolone was visible in any treated eyes. Others havereported that the triamcinolone present in a saline or other aqueoussuspension or solution is upon intravitreal administration cleared fromthe vitreous in about 21-41 days; using opthalmoscopic andspectrophotometric detection means to determine disappearance of theinjected triamcinolone, in non-vitrectomized rabbit eyes the averageclearance rate of intravitreally triamcinolone (0.5 mg) was 41 days,while in eyes having undergone vitrectomy or combination vitrectomy andlensectomy the average clearance rate was 17 days and 7 days,respectively. Schindler R. et al., The clearance of intravitrealtriamcinolone acetonide, Am J Opthalmol 1982; 93:415-417. Usinghigh-performance liquid chromatography (HPLC) complete clearance ofintravitreally injected triamcinolone (0.4 mg) in 24 rabbit eyes wasobserved by 21 days. Scholes G. et al., Clearance of triamcinolone fromvitreous, Arch Opthalmol 1985; 103:1567-1569.). Such rapid clearancefrom the vitreous can necessitate frequent re-administration (re-dosing)in order to effectively treat an ocular condition.

A triamcinolone pharmaceutical composition available under the tradename Kenalog® (Bristol-Myers-Squibb, Princeton N.J.) has been widelyused off-label to treat various ocular conditions, including byintravitreal administration. Significantly, Kenalog® is approved by theU.S. Food and Drug Administration only for intramuscular or intrabursaluse, but not for the treatment of any ocular conditions. Each milliliter(ml) of Kenalog® 40 composition comprises 40 milligrams (mg) oftriamcinolone acetonide, sodium chloride as a tonicity agent, 10 mg(0.99%) benzyl alcohol as a preservative, 7.5 mg (0.75%) ofcarboxymethylcellulose sodium and 0.4 mg (0.04%) of polysorbate 80 asresuspension aids.

It has been reported that Kenalog has a 15 day half life in the vitreouswith an effect on central macular thickness being observed for up to 140days after intravitreal injection of the Kenalog. Aubren, F. et al.,Pharmacokinetic-Pharmacodynamic modeling of the effect of TriamcinoloneAcetonide on Central Macular Thickness in is Patients with DiabeticMacular Edema, Inv Ophth & V is Sci, 45(10); 3435-3441: October 2004. Ithas also been reported that triamcinolone can be detected in thevitreous up to 93 days after a single intravitreal injection of Kenalog(Beer P. et al., Intraocular concentration and pharmacokinetics oftriamcinolone acetonide after a single intravitreal injection, Opthal110(4); 681-686: April 2003), with the triamcinolone estimated to bepotentially detectable in the vitreous for about 4 months. Inoue M. etal., Vitreous concentrations of triamcinolone acetonide in human eyesafter intravitreal or subtenon injection, Am J Opth 138(6); 1046-1048:2004.

Noninfectious endophthalmitis have been reported upon intravitrealKenalog® injection, possibly related to the preservative, excipientsand/or resuspension aids present in Kenalog® (Roth D. et al.,Noninfectious endophthalmitis associated with intravitreal triamcinoloneinjection, Arch Opthalmol 2003; 121: 1279-1282; Sutter F. et al.,Pseudo-endophthalmitis after intravitreal injection of triamcinolone, BrJ Opthalmol 2003; 87:972-974).

Additionally, the presence of benzyl alcohol preservative andpolysorbate 80 surfactant in Kenalog® can potentially damage or be toxicto sensitive ocular tissues, such as retinal cells, and for this reasonclinicians routinely wash the triamcinolone acetonide precipitate (whichforms when Kenalog® is left standing) several times with saline toreduce the concentration of these undesirable non-active materials fromthe formulation. Additionally, methods have been developed to filter outof Kenalog® and from identical formulations such as Kenacort-A thepreservative, surfactant, and/or resuspension (suspending agents) aidspresent in these formulations. Nishimura A. et al., IsolatingTriamcinolone acetonide particles for intravitreal use with a porousmembrane filter, Retina, vol 23(6); 777-779 (2003). Such washing and/orfiltering steps are inconvenient, time consuming, and increase thepossibility of microbial or endotoxin contamination that could lead tointraocular infection and inflammation.

Significantly, the triamcinolone acetonide in Kenalog® 40 tends torapidly separate and precipitate from the remainder of the composition.For example, if Kenalog® is left standing for as short a time as aboutfive to ten minutes a substantial separation of a triamcinoloneacetonide precipitate from the remainder of the composition occurs.Unfortunately, such rapid settling of the triamcinolone also occurs withother known saline based suspensions of triamcinolone (with or withpreservatives and stabilizers). Thus, if the composition is to beinjected into the eye it must first be vigorously shaken and usedpromptly after being so shaken in order to provide a substantiallyuniform suspension. A substantially uniform suspension (which is notprovided by Kenalog or other saline based suspensions of triamcinolone)is required in order to provide a consistent and accurate dose uponadministration of the suspension to the eye. In addition, resuspensionprocessing requires the use of the resuspension aids noted above, atleast one of which is less than totally desirable for sensitive oculartissues. At least because of the potential risk of noninfectiousendophthalmitis from use of the Kenalog® vehicle, development of apreservative-free triamcinolone formulation for intraocular use to treatan ocular condition (such as a posterior ocular condition) is desirable.

Elevated intraocular pressure, that is elevated anterior chamberintraocular pressure, depends on the comparative rates of aqueousproduction and aqueous drainage, primarily through the trabecularmeshwork. Increased intraocular pressure occurs from a variety ofmechanisms such as primary or secondary angle-closure glaucoma, primaryor secondary open-angle glaucoma, or combined-mechanism glaucoma. Ifinadequately treated, increased intraocular pressure may result inglaucomatous optic nerve changes and loss of visual field.

Known formulations of corticosteroids administered by a topical,systemic or peribulbar route can cause an increase in anterior chamberintraocular pressure. For example, following 4 to 6 weeks of topicalcorticosteroid administration, 5% of subjects can show an elevation inintraocular pressure of >16 mmHg and 30% of subjects may is show anelevation of 6 to 15 mmHg (Armaly M., Statistical attributes of thesteroid hypertensive response in the clinically normal eye, InvestOpthalmol V is Sci 1965; 4:187-197; Becker B,. Intraocular pressureresponse to topical corticosteroid, Invest Opthalmol V is Sci 1965;4:198-205). Additionally, intravitreal administration of knownformulations of a corticosteroid, such as triamcinolone can also resultin increased intraocular pressure (Martidis A. et al., Intravitrealtriamcinolone for refractory diabetic macular edema, Opthalmology 2002;109:920-927; Jonas J. et al., Intravitreal injection of triamcinolonefor diffuse diabetic macular edema, Arch Opthalmol 2003; 121:57-61),possibly due to the burst or high release rates of triamcinolone fromthe known formulations.

As well as causing an increase in intraocular pressure, corticosteroidscan also cause an increase in cataract formation. Corticosteroid-inducedcataracts typically show an axial, posterior subcapsular opacity, whichgradually increases in size. Nuclear sclerosis is not a typical lenschange from corticosteroids. Topical, systemic and peribulbarcorticosteroid administration have all been associated with an increasedrisk of cataract formation (Butcher J. et al., Bilateral cataracts andglaucoma induced by long term use of steroid eye drops. BMJ 1994;309-343).

The intravitreal administration of known triamcinolone formulations cantherefore also be expected to be associated with an increased risk ofboth elevated intraocular pressure and cataract formation.

A further adverse effect from ocular corticosteroid administration canbe inflammation. Endophthalmitis is a type of intraocular inflammationthat can be due to infection with pathogens such as bacteria of fungi orcan be noninfectious. Clinical features include lid edema, conjunctivalinjection, corneal edema, anterior chamber and vitreous inflammation andhypotonia. Infectious endophthalmitis can occur following an intraocularprocedure (i.e. cataract surgery, vitrectomy surgery, intravitrealinjection), as a result of systemic infection, as a result of trauma, oroccur as a late is feature of conjunctival filtering blebs.

The most common dose of triamcinolone used to treat eyes with macularedema associated with diabetes, CRVO or BRVO is 4 mg (Martidis A. etal., Intravitreal triamcinolone for refractory diabetic macular edema,Opthalmology 2002; 109:920-927). The use of 25 mg of triamcinolone hasless commonly been used to treat eyes with macular edema (Jonas J. etal., Intraocular injection of crystalline cortisone as adjunctivetreatment of diabetic macular edema, Am J Opthalmol 2001; 132:425-427).

Thus, there are significant drawbacks and deficiencies with the knowntriamcinolone formulations used by intravitreal administration to treatan ocular condition, including for example rapid clearance from thevitreous, elevated intraocular pressure, cataract formation, retinaltoxicity, and intraocular inflammation, such as endophthalmitis.

Hence, a sterile, preservative-free, sustained release triamcinolonepreparation is desirable. Additionally, because corticosteroids haveknown ocular toxicities (as manifested in the occurrence or developmentof for example elevated IOP, glaucoma and cataract) it is desirable tohave a triamcinolone formulation for intraocular (i.e. intravitreal) usewhich does not result in an increased incidence of elevated IOP,glaucoma, cataract formation and/or intraocular inflammation, or whichhas, subsequent to intraocular administration of a triamcinoloneformulation, a reduced incidence of elevated IOP, glaucoma, cataractformation and/or intraocular inflammation as compared to currently usedor known intraocular (i.e. intravitreal) use triamcinolone.

DRAWINGS

FIG. 1 is a bar graph of observed angiographic leakage (as assessed on a1-5 grading scale) on the Y-axis versus time of the observation on theX-axis for three groups of rabbit eyes: rabbit control (untreated) eyes,rabbit eyes intravitreally injected with the 1 mg triamcinoloneacetonide gel suspension (TAA_(gs)) formulation of Example 8, and rabbiteyes intravitreally injected with the 4 mg TAA_(gs) of Example 9. Thegrading (scale 1-5) of late-phase angiograms from rabbit eyes wasmeasured over a thirty week period after intravitreal injection ofeither the 1 mg TAA_(gs) or 4 mg TAA_(gs). All eyes receivedintravitreal injection of 500 ng VEGF at each of the time points shownon the X-axis followed by angiography 48 hrs later.

FIG. 2 is a bar graph of observed vitreoretinal fluorescence (as areaunder the curve) on the Y-axis versus time of the observation on theX-axis for the same three groups of rabbit eyes: rabbit control(untreated) eyes, rabbit eyes intravitreally injected with the 1 mgTAA_(gs), and rabbit eyes intravitreally injected with the 4 mg TAA_(gs)(as in FIG. 1). Scanning vitreal fluorophotometry measurements ofVEGF-induced BRB breakdown in rabbit eyes was measured over the samethirty week period after intravitreal injection of the 1 mg or 4 mgTAA_(gs). As in FIG. 1, all eyes had received intravitreal injection of500 ng VEGF at the time points shown on the X-axis followed byfluorophotometry 48 hrs later. The area under the fluorescence curve(AUC) was calculated for each eye.

FIG. 3 is a bar graph of observed retinal blood vessel caliber andtortuosity (grade) on the Y-axis versus time of the observation on theX-axis for the same rabbit control (untreated) eyes, rabbit eyesintravitreally injected with 1 mg TAA_(gs) or with 4 mg TAA_(gs) (as inFIG. 1). Subjective grading (on a 1-5 scale) of VEGF-induced changes invessel caliber and tortuosity from fundus images of rabbit eyes wasmeasured over the same thirty week period after intravitreal injectionof the 1 or 4 mg TAA_(gs). As in FIG. 1, all eyes received intravitrealinjection of 500 ng VEGF at the indicated time points followed by fundusimage capture 48 hrs later.

FIG. 4 is a bar graph of observed anterior chamber fluorescence (as areaunder the curve) on the Y-axis versus time of the observation on theX-axis for the same rabbit control (untreated) eyes, rabbit eyesintravitreally injected with 1 mg TAA_(gs) or with 4 mg TAA_(gs), (as inFIG. 1). Scanning ocular fluorophotometry of VEGF-induced blood-aqueousbarrier breakdown in rabbit eyes was measured over a thirty week periodafter intravitreal injection of either 1 or 4 mg TAA_(gs). As in FIG. 1,all eyes received intravitreal injection of 500 ng VEGF at the indicatedtime points followed by anterior chamber fluorophotometry 48 hrs later.The area under the fluorescence curve (AUC) was calculated for each eye.

FIG. 5 is a negative image of a photograph of the eye of a rabbit thirtyweeks after intravitreal injection of 50 μL of the Example 94 mgTAA_(gs) formulation. The photograph was taken with an 11.0 megapixel,digital Zeiss FF450 fundus camera coupled to the Zeiss 481 Visupac imagecapture and analysis system.

FIG. 6 is a flow chart which summarizes a preferred manufacturingprocess for making the triamcinolone formulations of Examples 1 to 9.

FIG. 7 consists of three bar graphs showing the size (diameter) inmicrons α-axis) of triamcinolone acetonide particles in three commerciallots of Kenalog-40 vs the frequency of occurrence of the measuredparticles diameters. Triamcinolone acetonide particle size diameter anddistribution was determined by laser light scattering using a Horiba LA300 instrument.

FIG. 8 consists of four bar graphs (A, B, C and D) showing the size(diameter) in microns (x-axis) of triamcinolone acetonide particles infour lots of the Example 9 (8% Trivaris) formulation vs the frequency ofoccurrence of the measured particles diameters. The line graph in FIGS.8A to 8D shows the area under the curve for cummulative (%)triamcinolone acetonide particle size (right hand side y axis).Triamcinolone acetonide particle size diameter and distribution wasdetermined by laser light scattering using a Horiba LA 300 instrument.

SUMMARY

The present invention provides sterile, preservative-free, sustainedrelease triamcinolone formulations for treating ocular conditions withthe desirable characteristics of low ocular toxicities, as manifested inthe low or nominal occurrence or development of an elevated IOP,glaucoma, cataract and/or intraocular inflammation.

Definitions

As used herein, the words or terms set forth below have the followingdefinitions.

“About” means that the item, parameter or term so qualified encompassesa range of plus or minus ten percent above and below the value of thestated item, parameter or term.

“Administration”, or “to administer” means the step of giving (i.e.administering) a pharmaceutical composition to a subject. Thepharmaceutical compositions disclosed herein can be “locallyadministered”, that is administered at or in the vicinity of the site atwhich a therapeutic result or outcome is desired. For example to treatan ocular condition (such as for example a macular edema, uveitis ormacular degeneration) intravitreal injection or implantation of asustained release device such as active agent containing polymericimplant can be carried out. “Sustained release” means release of anactive agent (such as a triamcinolone) over a period of about seven daysor more, while “extended release” means release of an active agent overa period of time of less than about seven days.

“Entirely free (i.e. “consisting of” terminology) means that within thedetection range of the instrument or process being used, the substancecannot be detected or its presence cannot be confirmed.

“Essentially free” (or “consisting essentially of”) means that onlytrace amounts of the substance can be detected.

“Pharmaceutical composition” means a formulation in which an activeingredient (the active agent) can be a steroid, such as acorticosteroid, such as a triamcinolone. The word “formulation” meansthat there is at least one additional ingredient in the pharmaceuticalcomposition besides the steroid active ingredient. A pharmaceuticalcomposition is therefore a formulation which is suitable for diagnosticor therapeutic administration (i.e. by intraocular injection or byinsertion of a depot or implant) to a subject, such as a human patient.

“Substantially free” means present at a level of less than one percentby weight of the pharmaceutical composition.

All the viscosity values set forth herein were determined at 25° C.(unless another temperature is specified). Additionally, all theviscosity values set forth herein were determined at a shear rate ofabout 0.1/second (unless another shear rate is specified).

The present compositions are highly suitable for intravitrealadministration into the posterior segments of eyes without requiring anywashing step, while providing for reduced ocular, for example, retinal,damage when used in an eye. The present compositions are advantageouslysubstantially free of added preservative components, for example,contain no benzyl alcohol preservative. In addition, the presentcompositions advantageously require no resuspension aid or aids.Overall, the present compositions are easily and effectively injectableinto the posterior segment of an eye of a human or animal and can bemaintained as a substantially uniform suspension for long periods oftime, for example, at least about one week or more, without resuspensionprocessing, for example, without requiring shaking or other agitating ofthe composition to obtain substantial suspension uniformity. In short,is the present compositions and methods provide substantial enhancementsand advantages, for example, relative to the prior art Kenalog® 40composition and methods of using such prior art composition, in theposterior segments of human or animal eyes.

In one broad aspect of the present invention, compositions useful forinjection into a posterior segment of an eye of a human or animal areprovided. Such compositions comprise a corticosteroid component, aviscosity inducing component, and an aqueous carrier component. Thecorticosteroid component is present in a therapeutically effectiveamount. The corticosteroid component is present in the compositions in aplurality of particles.

The present compositions may include a corticosteroid component in anamount of up to about 25% (w/v) or more of the composition. In one veryuseful embodiment, the corticosteroid component is present in an amountof at least about 80 mg/ml of composition. Preferably, thecorticosteroid component is present in an amount in a range of about 1%to about 10% or about 20% (w/v) of the composition.

In one very useful embodiment, the corticosteroid component comprisestriamcinolone acetonide. The viscosity inducing component is present inan amount effective in increasing the viscosity of the composition. Anysuitable, preferably ophthalmically acceptable, viscosity inducingcomponent may be employed in accordance with the present invention. Manysuch viscosity inducing components have been proposed and/or used inophthalmic compositions used on or in the eye. Advantageously, theviscosity inducing component is present in an amount in a range of about0.5% to about 20% (w/v) of the composition. In one particularly usefulembodiment, the viscosity inducing component is a hyaluronic acidpolymer component, such as sodium hyaluronate.

In one embodiment, the present compositions have a viscosity of at leastabout 10 cps or at least about 100 cps, preferably at least about 1,000cps, more preferably at least about 10,000 cps and still more preferablyat least about 70,000 cps, for example, up to about 250,000 cps, orabout 300,000 cps, at a shear rate of 0.1/second. The presentcompositions are structured or have make-ups so as to be effectively,for example, manually, injected into a posterior segment of an eye of ahuman or animal, preferably through a 27 gauge needle, more preferablythrough a 29 or 30 gauge needle.

Without wishing to limit the invention to any particular theory ofoperation, it is believed that the use of relatively high viscositycompositions, as described herein, provides for effective, andpreferably substantially uniform, suspension of the steroid componentparticles while, at the same time, being injectable into the posteriorsegment of an eye through conventionally, or even smaller thanconventionally, used needles.

In one embodiment of the invention, the corticosteroid component ispresent in a plurality of particles which are substantially uniformlysuspended in the composition and remain substantially uniformlysuspended in the composition for at least about 1 week, preferably atleast about 2 weeks or at least about 1 month, and still more preferablyat least about 6 months or at least about 1 year or at least about 2years, without requiring resuspension processing, that is, withoutrequiring being shaken or otherwise agitated to maintain thecorticosteroid component particles substantially uniformly suspended inthe composition.

Compositions having such substantially uniform suspension ofcorticosteroid component particles, so as to be able to provide aconsistent and accurate dose upon administration to an eye, providesubstantial advantages relative to the prior art. In particular, thepresent compositions may be manufactured, shipped and stored forsubstantial periods of time without the corticosteroid componentparticles precipitating is from the remainder of the composition. Havingthe corticosteroid component particles maintained substantiallyuniformly suspended in the composition allows the composition to providelong term dosing consistency and accuracy per unit dose amountadministered, without any need to resuspend the corticosteroidparticles.

The aqueous carrier component is advantageously ophthalmicallyacceptable and may include one or more conventional expedients useful inophthalmic compositions. For example, the carrier component may includean effective amount of at least one of a preservative component, atonicity component and a buffer component. In one advantageousembodiment, the present compositions include no added preservativecomponent. This feature reduces or minimizes or even substantiallyeliminates adverse reactions in the eye which may be caused by or linkedto the presence of a preservative component. Although a resuspensioncomponent may be employed in accordance with the present invention, inmany instances, because of the ability of the present composition toremain a substantially uniform suspension for a long period of timewithout requiring resuspension processing, the compositionsadvantageously contain no added resuspension components.

Methods of treating posterior segments of the eyes of humans or animalsare also disclosed and are included within the scope of the presentinvention. In general, such methods comprise administering, e.g.injecting a corticosteroid component-containing composition, forexample, a composition in accordance with the present intention, to aposterior segment of an eye of a human or animal. Such administering iseffective in providing a desired therapeutic effect. The administeringstep advantageously comprises at least one of intravitreal injecting,subconjunctival injecting, sub-tenon injecting, retrobulbar injecting,suprachoroidal injecting and the like.

Our invention encompasses a pharmaceutical composition for treating aposterior ocular condition. The composition can comprise a triamcinolonepresent in a therapeutically effective amount as a plurality ofparticles; a viscosity inducing component in an amount effective toincrease the viscosity of the composition, and; an aqueous carriercomponent. The composition can have a viscosity of at least about 10 cpsat a shear rate of about 0.1/second and is injectable into the vitreousof a human eye, for example through a 27 gauge needle. By reducing theviscosity of our formulation it can be injected into the vitreousthrough a 28, 29 or 30 gauge needle.

Preferably, the triamcinolone particles of the pharmaceuticalcomposition are substantially uniformly suspended in the composition andthe viscosity inducing component is a polymeric hyaluronate.

A detailed embodiment within the scope of our invention is apharmaceutical composition for treating a posterior ocular condition,comprising triamcinolone particles; polymeric hyaluronate, in which thetriamcinolone particles are suspended; sodium chloride; sodiumphosphate, and water. The pharmaceutical composition can have aviscosity at a shear rate of about 0.1/second of between about 80,000cps to about 300,000, preferably from about 100,000 cps to about 300,000cps, and most preferably from about 1280,000 cps to about 225,000 cps.Note that the pharmaceutical composition can have a viscosity at a shearrate of about 0.1/second of between about 80,000 cps and about 300,000cps, and that when the pharmaceutical composition has a viscosity at ashear rate of about 0.1/second of between about 100,000 cps and about150,000 cps it can be injected into the vitreous through a 27, 28, 29 or30 gauge needle. We have found that even with a 300,000 cps ourformulations can be injected through a 30 gauge needle due to shearthinning once the formulation is in movement in the syringe. The sodiumphosphate present in the pharmaceutical composition can comprise bothmonobasic sodium phosphate and dibasic sodium phosphate. Additionally,the pharmaceutical composition can comprise between about 2% w/vtriamcinolone and about 8% w/v triamcinolone, between about 2% w/vhyaluronate and about 3% w/v hyaluronate, about 0.6% w/v sodium chlorideand about 0.03% w/v sodium phosphate to about 0.04% w/v sodiumphosphate. Alternately, the pharmaceutical composition of claim 5 cancomprise between about is 0.5% w/v hyaluronate and about 6% w/vhyaluronate. If desired the hyaluronate can be heated (see Example 15)to decrease its molecular weight (and therefore its viscosity) in theformulation.

The pharmaceutical composition can also comprises between about 0.6% w/vsodium chloride to about 0.9% w/v sodium chloride. Generally, moresodium chloride is used in the formulation as less phosphate is used inthe formulation, for example 0.9% sodium chloride can be used if nophosphate is present in the formulation, as in this manner the tonicityof the formulation can be adjusted to obtain the desired isotonicitywith physiological fluid. The pharmaceutical composition can comprisebetween about 0.0% w/v sodium phosphate and 0.1% w/v sodium phosphate.As noted, more phosphate can be used in the formulation if less sodiumchloride is present in the formulation so as to obtain a desired pH 7.4buffering effect.

A more detailed embodiment within the scope of our invention is apharmaceutical composition for treating a posterior ocular condition,the pharmaceutical composition consisting essentially of triamcinoloneparticles, polymeric hyaluronate, in which polymeric hyaluronate thetriamcinolone particles are suspended, sodium chloride, sodiumphosphate, and water. The pharmaceutical composition can have aviscosity at a shear rate 0.1/second at 25° C. of between about 128,000cps and about 225,000 cps and the sodium phosphate present in thepharmaceutical composition can be present as both monobasic sodiumphosphate and dibasic sodium phosphate. The most preferable viscosityrange is 140,000 to 280,000 cps at a shear rate 0.1/second at 25° C.

A further embodiment of our invention is a triamcinolone suspension fortreating a posterior ocular condition, consisting of triamcinoloneparticles, polymeric hyaluronate, in which the triamcinolone particlesare suspended, sodium chloride, dibasic sodium phosphate heptahydrate,monobasic sodium phosphate monohydrate, and water, wherein thecomposition has a viscosity at a shear rate 0.1/second of between aboutis 128,000 cps and about 225,000 cps.

Our invention also includes a method for treating a posterior ocularcondition by administering (as by injecting) the pharmaceuticalcomposition of claim 1 to the vitreous of a human or animal, therebytreating the posterior ocular condition. Thus we have invented a methodfor treating macula edema by administering to the vitreous of a humaneye a pharmaceutical composition comprising a triamcinolone, and ahyaluronate, wherein the pharmaceutical composition having a viscosityat a shear rate 0.1/second of between about 128,000 cps and about225,000 cps.

A pharmaceutical composition within the scope of our invention fortreating a posterior ocular condition can comprise a triamcinolonepresent in a therapeutically effective amount as a plurality ofparticles, a viscosity inducing component in an amount effective toincrease the viscosity of the composition, and an aqueous carriercomponent, wherein the composition has a viscosity of at least about 10cps at a shear rate of 0.1/second and is injectable into the vitreous ofa human eye and wherein the pharmaceutical composition releases thetriamcinolone with substantially first order release kinetics over aperiod of at least about 45 days after the intravitreal injection. Thispharmaceutical composition can exhibit reduced generation of intraocularinflammation, no plume effect (that is no wide dispersion of thetriamcinolone into the vitreous as soon as the triamcinolone isintravitreally injected), and cohesiveness (as shown by the retention ofthe form of the triamcinolone gel for 30 weeks or longer afterintravitreal injection of the triamcinolone gel formulation) uponintravitreal injection of the pharmaceutical composition.

Our invention encompasses a method for treating a posterior ocularcondition, the method comprising the step of intravitreal administrationof a sustained release pharmaceutical composition implant comprising atriamcinolone present in a therapeutically effective amount as aplurality of particles, a viscosity inducing component in an amounteffective to increase the viscosity of the composition, and an isaqueous carrier component, wherein the composition has a viscosity of atleast about 10 cps at a shear rate of 0.1/second and is injectable intothe vitreous of a human eye, and wherein the posterior ocular conditionis treated for up to about 30 weeks by the triamcinolone released fromthe implant. In this method the pharmaceutical composition can comprisetriamcinolone particles, polymeric hyaluronate, in which thetriamcinolone particles are suspended, sodium chloride, sodiumphosphate, and water. Additionally, the intravitreal administration canbe injected through a 27 gauge needle into the vitreous of a human eye,and in an aggregate number of patients practise of the method results inless intraocular inflammation than does practise of the same method witha second pharmaceutical composition which is a saline solution orsuspension of a triamcinolone.

Our invention also includes a process for making a pharmaceuticalcomposition by (a) mixing triamcinolone particles about 4 microns toabout 8 microns in diameter with sodium chloride crystals, and about 35%to about 40% of the total volume of the water (water for injection) usedto make the formulation; (b) heating the triamcinolone and sodiumchloride mixture to a temperature between about 120° C. and about 140°C., thereby preparing a first part; (c) mixing a sodium phosphate andwater, thereby preparing a second part; (d) dissolving sodiumhyaluronate with a molecular weight between about 1.0 million Daltonsand about 1.9 million Daltons in another about 35% to about 40% of thetotal water volume used to make the formulation, followed by sterilefiltration after the dissolving; (e) lyophilization of the dissolvedsodium hyaluronate; (f) reconstitution of the lyophilized, sterilesodium hyaluronate, thereby preparing a third part; and; (g) asepticallycombining the first, second and third parts, thereby making a sterile,uniform triamcinolone pharmaceutical composition which is, an opaquewhite gel suspension suitable for intravitreal injection to treat anocular condition. Water is added as needed (q.s.) to make the desiredgel suspension which is about 80% to about 90% by weight water.

Also within the scope of our invention is a pharmaceutical compositionfor treating a posterior ocular condition, the pharmaceuticalcomposition comprising a plurality of corticosteroid particles mixedwith a viscous polymer, wherein the pharmaceutical composition has aviscosity of between about 130,000 cps and about 300,000 cps at a shearrate of about 0.1/second at about 25° C., and the pharmaceuticalcomposition can be injected into the vitreous of a human eye through a25 to 33 gauge needle. The corticosteroid particles can have asubstantially uniform diameter, as shown for example by FIGS. 8A, 8B, 8Cand 8D. Additionally, preferably substantially all (i.e. up to 90-97%)of the corticosteroid particles are embedded within the viscous polymer.The corticosteroid can be a triamcinolone and the viscous polymer can bea polymeric hyaluronate or a polymeric hyaluronic acid.

An alternate method for treating a posterior ocular condition cancomprise the step of injecting into the vitreous of a patient's eye witha posterior ocular condition a viscous pharmaceutical compositioncomprising a plurality of corticosteroid particles mixed into a viscouspolymeric matrix, wherein the pharmaceutical composition has a viscosityof between about 130,000 cps and about 300,000 cps at a shear rate ofabout 0.1/second at about 25° C., such that about one hour after theintravitreal injection only about 10% or less (or only about 5% or lessor only about 3% or less) of the corticosteroid particles are present inthe vitreous free of the polymeric matrix.

An alternate process for making an intraocular pharmaceuticalcomposition can comprise the step of mixing an aqueous suspension of aplurality of corticosteroid particles and an aqueous solution of aviscous polymeric matrix, so that the resulting pharmaceuticalcomposition has a viscosity of between about 130,000 cps and about300,000 cps at a shear rate of about 0.1/second at about 25° C. Thecorticosteroid particles can have a median particle size of betweenabout 4 microns and about 5 microns. By use of this process for makingan intraocular pharmaceutical composition the corticosteroid particlescan have a stable diameter for at least three months after thepharmaceutical has been made and stored for three months in a syringeplaced horizontally at about 25° C. at about 60% relative humidity.

Our invention also includes a pharmaceutical composition for treating anarticular pathology, the pharmaceutical composition comprising aplurality of corticosteroid particles mixed with a viscous polymer,wherein the pharmaceutical composition has a viscosity of between about130,000 cps and about 300,000 cps at a shear rate of about 0.1/second atabout 25° C.

Finally, our invention also includes a method for treating an articularpathology, the method comprising the step of injecting into a joint of apatient with an articular pathology (such as a joint or spineinflammation) a viscous pharmaceutical composition comprising aplurality of corticosteroid particles mixed into a viscous polymericmatrix, wherein the pharmaceutical composition has a viscosity ofbetween about 130,000 cps and about 300,000 cps at a shear rate of about0.1/second at about 25° C.

Description

The present invention is based upon our discovery of triamcinoloneformulations specifically designed for intravitreal injection to treatvarious ocular conditions, such a macula edema. Our triamcinoloneformulations have numerous superior characteristics and advantages,including the following: (1) the triamcinolone present in ourformulations does not rapidly settle out from or precipitate from theformulations. Importantly our formulations have a shelf life of at leasttwo years, meaning that our formulations can be left standing for up toabout two years before administration to an eye, and after two years theformulation can still provide a consistent and accurate dose oftriamcinolone upon injection to the formulation to an eye; (2) ourformulations are free of preservatives and resuspension aids, such asbenzyl alcohol and/or a polysorbate; (3) concomitantly, our formulationshave a much reduced retinal and photoreceptor toxicity; (4) as well asbeing sterile and preservative-free our triamcinolone formulations canprovide sustained release of therapeutic amounts of the triamcinoloneover multi-month periods upon intravitreal injection of suchformulations. Thus, our viscous suspension triamcinolone formulationscan be characterized as sustained release implants; (5) intravitrealadministration of our triamcinolone formulations is not associated withan increased incidence of adverse events such as elevated intra ocularpressure, glaucoma, cataract and/an intraocular inflammation; (6)intravitreal administration of our triamcinolone formulations is notassociated with an increased incidence of adverse events such elevatedintra ocular pressure, glaucoma, cataract and/an intraocularinflammation as compared to currently used or known intraocular (i.e.intravitreal) use triamcinolone formulations; (7) our formulationspermit triamcinolone particles (crystals) to be released (as theysolubilize in the viscous fluid of the posterior chamber) from adiscrete unitary location, thereby avoiding the plume effect (rapiddispersion) characteristic of aqueous triamcinolone formulations uponintravitreal administration; (8) avoidance of plume formation or rapiddispersion upon intravitreal administration beneficially reduces visualfield obscuration; (9) the sustained release characteristic of ourformulations reduces the need for intravitreal administration of largedrug quantities to achieve a desired therapeutic effect; (10) uponintravitreal administration, the triamcinolone present in ourformulations can preferentially be eliminated in posterior direction(that is through the retina and optic nerve) as opposed to eliminationthrough an anterior route (see eg Table 5). This can result in superiortreatment of a retinal disease with for example reduced ocularhypertension.

Advantage (1) above can be provided by formulating the triamcinolone asa viscous, gel suspension, as opposed to formulating it as an aqueous orsaline based formulation. Additionally, advantages (4) and (8) above canbe provided by particular characteristics of our formulations, such assuspension of the triamcinolone in one or more particular high molecularweight hydrogel polymers which permit sustained release of thetriamcinolone from a biocompatible, biodegradable polymeric matrix, andother implant-like characteristics to the formulations, includingsubstantially zero-order in vivo (i.e. intravitreal) release kinetics(see eg Table 4).

The pluming effect occurs when a saline suspension of a triamcinolone(such as Kenalog) is injected into the vitreous. Pluming preventsvisualization of the back of the eye (i.e. the retina is obscured) andalso reduces the patient's visual field (reduced vision).

Generally, the present invention provides compositions useful forplacement, preferably by injection, into a posterior segment of an eyeof a human or animal. Such compositions in the posterior, e.g.,vitreous, of the eye are therapeutically effective against one or moreconditions and/or diseases of the posterior of the eye, and/or one ormore symptoms of such conditions and/or diseases of the posterior of theeye.

It is important to note that while preferably the compositions disclosedherein are preferably administered by intravitreal injection to treat aposterior ocular condition, our compositions (i.e. those of Examples 8and 9) can also be administered (as by injection) by other routes, suchas for example subconjuctival, sub-tenon, periocular, retrobulbar,suprachoroidal, and/or intrascleral to effectively treat an ocularcondition. Additionally, a sutured on refillable dome can be placed overthe administration site to prevent or to reduce wash out, leachingand/or diffusion of the active agent in a non-preferred direction.

Compositions within the scope of our invention can comprise acorticosteroid component; a viscosity inducing component; and an aqueouscarrier component. The compositions are advantageously ophthalmicallyacceptable. One of the important advantages of the present compositionsis that they are more compatible with or friendly to the tissues in theposterior segment of the eye, for example, the retina of the eye,relative to compositions previously proposed for intravitreal injectioninto a posterior segment of an eye, for example, a composition soldunder the trademark Kenalog®-40. In particular, the present compositionsadvantageously are substantially free of added preservative componentsor include effective preservative components which are more compatiblewith or friendly to the posterior segment, e.g., is retina, of the eyerelative to benzyl alcohol, which is included in the Kenalog®-40composition as a preservative.

In addition, the present compositions preferably include no addedresuspension component, such as polysorbate-80, which is included in theKenalog®-40 composition. Many of the other features of the presentcompositions, as described elsewhere herein, also render the presentcompositions more compatible with or friendly to the posterior segmentsof the eyes into which the compositions are placed relative to prior artcompositions, such as Kenalog®-40.

As noted above, the present compositions include a corticosteroidcomponent. Such corticosteroid component is present in the compositionsin a therapeutically effective amount, that is in an amount effective inproviding a desired therapeutic effect in the eye into which thecomposition is placed. The corticosteroid component is present in thecomposition in a plurality of particles. Any suitable corticosteroidcomponent may be employed in according to the present invention. Suchcorticosteroid component advantageously has a limited solubility inwater, for example, at 25° C. For example, the corticosteroid componentpreferably has a solubility in water at 25° C. of less than 10 mg/ml. Ofcourse, the corticosteroid component should be ophthalmicallyacceptable, that is, should have substantially no significant or unduedetrimental effect of the eye structures or tissues. One particularlyuseful characteristic of the presently useful corticosteroid componentsis the ability of such component to reduce inflammation in the posteriorsegment of the eye into which the composition is placed caused by theresult of one or more diseases and/or conditions in the posteriorsegment of the eye.

Examples of useful corticosteroid components include, withoutlimitation, cortisone, prednesolone, triamcinolone, triamcinoloneacetonide, fluorometholone, dexamethosone, medrysone, loteprednol,derivatives thereof and mixtures thereof. As is used herein, the term“derivative” refers to any substance which is sufficiently structurallysimilar to the material of which it is identified as a derivative so asto have substantially similar functionality or activity, for example,therapeutic effectiveness, as the material when the substance is used inplace of the material. In one very useful embodiment, the corticosteroidcomponent comprises triamcinolone acetonide.

The corticosteroid component advantageously is present in an amount ofat least about 10 mg per ml of the composition. One important advantageof the present invention is the effective ability of the presentcompositions to include relatively large amounts or concentrations ofthe corticosteroid component. Thus, the corticosteroid component may bepresent in the present compositions in an amount in the range of about1% or less to about 5% or about 10% or about 20% or about 30% or more(w/v) of the composition. Providing relatively high concentrations oramounts of corticosteroid component in the present compositions isbeneficial in that reduced amounts (volumes for injection) of thecomposition may be required to be placed or injected into the posteriorsegment of the eye in order to provide the same amount or morecorticosteroid component in the posterior segment of the eye relative tocompositions, such as Kenalog®-40, which include less than 4% (w/v) ofthe corticosteroid component. Thus, in one very useful embodiment, thepresent compositions include more than about 4% (w/v), for example atleast about 5% (w/v), to about 10% (w/v) or about 20% (w/v) or about 30%(w/v) of the corticosteroid component. For example, about 50 μL of ourExample 8 or 9 formulation provide respectively 2 mg and 4 mg oftriamcinolone. This is in contrast to other formulations (such asKenalog 40) which require 100 μL to provide 4 mg of triamcinolone.Injection of 100 μL or more of a fluid into the vitreous can result inan excess of fluid in the vitreous with elevated intraocular pressureand leakage of the fluid from the vitreous then potentially occurring.

The viscosity inducing component is present in an effective amount inincreasing, advantageously substantially increasing, the viscosity ofthe composition. Without is wishing to limit the invention to anyparticular theory of operation, it is believed that increasing theviscosity of the compositions to values well in excess of the viscosityof water, for example, at least about 100 cps at a shear rate of0.1/second, compositions which are highly effective for placement, e.g.,injection, into the posterior segment of an eye of a human or animal areobtained. Along with the advantageous placement or injectability of thepresent compositions into the posterior segment, the relatively highviscosity of the present compositions are believed to enhance theability of the present compositions to maintain the corticosteroidcomponent particles in substantially uniform suspension in thecompositions for prolonged periods of time, for example, for as long as1 to 2 years, without requiring resuspension processing. The relativelyhigh viscosity of the present compositions may also have an additionalbenefit of at least assisting the compositions to have the ability tohave an increased amount or concentration of the corticosteroidcomponent, as discussed elsewhere herein, for example, while maintainingsuch corticosteroid component in substantially uniform suspension forprolonged periods of time.

Advantageously, the present compositions have viscosities of at leastabout 10 cps or at least about 100 cps or at least about 1000 cps, morepreferably at least about 10,000 cps and still more preferably at leastabout 70,000 cps or more, for example up to about 200,000 cps or about250,000 cps, or about 300,000 cps or more, at a shear rate of0.1/second. The present compositions not only have the relatively highviscosity as noted above but also have the ability or are structured ormade up so as to be effectively placeable, e.g., injectable, into aposterior segment of an eye of a human or animal, preferably through a27 gauge needle, or even through a 30 gauge needle.

The presently useful viscosity inducing components preferably are shearthinning components in that as the present composition containing such ashear thinning viscosity inducing component is passed or injected intothe posterior segment of an eye, for example, through a narrow space,such as 27 gauge needle, under high shear conditions the viscosity ofthe composition is substantially reduced during such passage. After suchpassage, the composition regains substantially its pre-injectionviscosity so as to maintain the corticosteroid component particles insuspension in the eye.

Any suitable viscosity inducing component, for example, ophthalmicallyacceptable viscosity inducing component, may be employed in accordancewith the present invention. Many such viscosity inducing components havebeen proposed and/or used in ophthalmic compositions used on or in theeye. The viscosity inducing component is present in an amount effectivein providing the desired viscosity to the composition. Advantageously,the viscosity inducing component is present in an amount in a range ofabout 0.5% or about 1.0% to about 5% or about 10% or about 20% (w/v) ofthe composition. The specific amount of the viscosity inducing componentemployed depends upon a number of factors including, for example andwithout limitation, the specific viscosity inducing component beingemployed, the molecular weight of the viscosity inducing component beingemployed, the viscosity desired for the present composition beingproduced and/or used and the like factors, such as shear thinning. Theviscosity inducing component is chosen to provide at least oneadvantage, and preferably multiple advantages, to the presentcompositions, for example, in terms of each of injectability into theposterior segment of the eye, viscosity, sustainability of thecorticosteroid component particles in suspension, for example, insubstantially uniform suspension, for a prolonged period of time withoutresuspension processing, compatibility with the tissues in the posteriorsegment of the eye into which the composition is to be placed and thelike advantages. More preferably, the selected viscosity inducingcomponent is effective to provide two or more of the above-notedbenefits, and still more preferably to provide all of the above-notedbenefits.

The viscosity inducing component preferably comprises a polymericcomponent and/or at least one viscoelastic agent, such as thosematerials which are useful in ophthalmic surgical procedures.

Examples of useful viscosity inducing components include, but are notlimited to, hyaluronic acid (such as a polymeric hyaluronic acid),carbomers, polyacrylic acid, cellulosic derivatives, polycarbophil,polyvinylpyrrolidone, gelatin, dextrin, polysaccharides, polyacrylamide,polyvinyl alcohol, polyvinyl acetate, derivatives thereof and mixturesand copolymers thereof.

The molecular weight of the presently useful viscosity inducingcomponents may be in a range of about 10,000 Daltons or less to about 2million Daltons or more. In one particularly useful embodiment, themolecular weight of the viscosity inducing component is in a range ofabout 100,000 Daltons or about 200,000 Daltons to about 1 millionDaltons or about 1.5 million Daltons. Again, the molecular weight of theviscosity inducing component useful in accordance with the presentinvention, may vary over a substantial range based on the type ofviscosity inducing component employed, and the desired final viscosityof the present composition in question, as well as, possibly one or moreother factors.

In one very useful embodiment, a viscosity inducing component is apolymeric hyaluronate component, for example, a metal hyaluronatecomponent, preferably selected from alkali metal hyaluronates, alkalineearth metal hyaluronates and mixtures thereof, and still more preferablyselected from sodium hyaluronates, and mixtures thereof. The molecularweight of such hyaluronate component (i.e. a polymeric hyaluronic acid)preferably is in a range of about 50,000 Daltons or about 100,000Daltons to about 1.3 million Daltons or about 2 million Daltons. In oneembodiment, the present compositions include a polymeric hyaluronatecomponent in an amount in a range about 0.05% to about 0.5% (w/v). In afurther useful embodiment, the hyaluronate component is present in anamount in a range of about 1% to about 4% (w/v) of the composition. Inthis latter case, the very high polymer viscosity forms a gel that slowsparticle sedimentation rate to the extent that often no resuspensionprocessing is necessary over the estimated shelf life, for example, atleast about 2 years, of the composition. Such a composition may bemarketed in pre-filled syringes since the gel cannot be easily removedby a needle and syringe from a bulk container. Pre-filled syringes havethe advantages of convenience for the injector and the safety whichresults from less handling.

The aqueous carrier component is advantageously ophthalmicallyacceptable and may include one or more conventional excipients useful inophthalmic compositions. The present compositions preferably include amajor amount of liquid water. The present compositions may be, and arepreferably, sterile, for example, prior to being used in the eye.

The present compositions preferably include at least one buffercomponent in an amount effective to control the pH of the compositionand/or at least one tonicity component in an amount effective to controlthe tonicity or osmolality of the compositions. More preferably, thepresent compositions include both a buffer component and a tonicitycomponent.

The buffer component and tonicity component may be chosen from thosewhich are conventional and well known in the ophthalmic art. Examples ofsuch buffer components include, but are not limited to, acetate buffers,citrate buffers, phosphate buffers, borate buffers and the like andmixtures thereof. Phosphate buffers are particularly useful. Usefultonicity components include, but are not limited to, salts, particularlysodium chloride, potassium chloride, mannitol and other sugar alcohols,and other suitable ophthalmically acceptably tonicity component andmixtures thereof.

The amount of buffer component employed preferably is sufficient tomaintain the pH of the composition in a range of about 6 to about 8,more preferably about 7 to about 7.5. The amount of tonicity componentemployed preferably is sufficient to provide an osmolality to thepresent compositions in a range of about 200 to about 400, morepreferably about 250 to about 350, mOsmol/kg respectively.Advantageously, the present compositions are substantially isotonic.

The present compositions may include one or more other components inamounts effective to provide one or more useful properties and/orbenefits to the present compositions. For example, although the presentcompositions may be substantially free of added preservative components,in other embodiments, the present compositions include effective amountsof preservative components, preferably such components which are morecompatible with or friendly to the tissue in the posterior segment ofthe eye into which the composition is placed than benzyl alcohol.Examples of such preservative components include, without limitation,benzalkonium chloride, chlorhexidine, PHMB (polyhexamethylenebiguamide), methyl and ethyl parabens, hexetidine, chlorite components,such as stabilized chlorine dioxide, metal chlorites and the like, otherophthalmically acceptable preservatives and the like and mixturesthereof. The concentration of the preservative component, if any, in thepresent compositions is a concentration effective to preserve thecomposition, and is often in a range of about 0.00001% to about 0.05% orabout 0.1% (w/v) of the composition.

In addition, the present composition may include an effective amount ofresuspension component effective to facilitate the suspension orresuspension of the corticosteroid component particles in the presentcompositions. As noted above, in certain embodiments, the presentcompositions are free of added resuspension components. In otherembodiments of the present compositions effective amounts ofresuspension components are employed, for example, to provide an addeddegree of insurance that the corticosteroid component particles remainin suspension, as desired and/or can be relatively easily resuspended inthe present compositions, such resuspension be desired. Advantageously,the resuspension component employed in accordance with the presentinvention, if any, is chosen to be more compatible with or friendly tothe tissue in the posterior segment of the eye into which thecomposition is placed than polysorbate 80.

Any suitable resuspension component may be employed in accordance withthe present invention. Examples of such resuspension components include,without limitation, surfactants such as poloxanes, for example, soldunder the trademark Pluronic®; tyloxapol; sarcosinates; polyethoxylatedcastor oils, other surfactants and the like and mixtures thereof.

One very useful class of resuspension components are those selected fromvitamin derivatives. Although such materials have been previouslysuggested for use as surfactants in ophthalmic compositions, they havebeen found to be effective in the present compositions as resuspensioncomponents. Examples of useful vitamin derivatives include, withoutlimitation, Vitamin E tocopheryl polyethylene glycol succinates, such asVitamin E tocopheryl polyethylene glycol 1000 succinate (Vitamin ETPGS). Other useful vitamin derivatives include, again withoutlimitation, Vitamin E tocopheryl polyethylene glycol succinamides, suchas Vitamin E tocopheryl polyethylene glycol 1000 succinamide (Vitamin ETPGSA) wherein the ester bond between polyethylene glycol and succinicacid is replaced by an amide group.

The presently useful resuspension components are present, if at all, inthe compositions in accordance with the present invention in an amounteffective to facilitate suspending the particles in the presentcompositions, for example, during manufacture of the compositions orthereafter. The specific amount of resuspension component employed mayvary over a wide range depending, for example, on the specificresuspension component being employed, the specific composition in whichthe resuspension component is being employed and the like factors.Suitable concentrations of the resuspension component, if any, in thepresent compositions are often in a range of about 0.01% to about 5%,for example, about 0.02% or about 0.05% to about 1.0% (w/v) of thecomposition.

The availability of minimally soluble corticosteroid components, such astriamcinolone acetonide, to intraocular tissues may be limited by thedissolution rate for these substances. Slow dissolution is both good andbad for the patient. On the one hand, after a single intravitrealinjection of the present composition, the mean elimination half-life fortriamcinolone acetonide is advantageously quite long, for example, about19 days in nonvitrectonized patients and measurable drug levels aredetected for up to about 3 months. On the other hand, therapeutic druglevels in the vitreous compartment of the eye may not be achieved forabout 1 to about 3 days, due to the slow dissolution rate of thecorticosteroid component particles.

In one embodiment of the present invention, an effective amount of asolubilizing component is provided in the composition to solubilize aminor amount, that is less than 50%, for example in a range of 1% orabout 5% to about 10% or about 20% of the corticosteroid component. Forexample, the inclusion of a cyclodextrin component, such asβ-cyclodextrin, sulfo-butylether β-cyclodextrin (SBE), othercyclodextrins and the like and mixtures thereof, at about 0.5 to about5.0% (w/v) solubilizes about 1 to about 10% of the initial dose oftriamcinolone acetonide. This presolubilized fraction provides a readilybioavailable loading dose, thereby avoiding any delay time intherapeutic effectiveness.

The use of such a solubilizing component is advantageous to provide anyrelatively quick release of the corticosteroid component into the eyefor therapeutic effectiveness. Such solubilizing component, of course,should be ophthalmically acceptable or at least sufficiently compatiblewith the posterior segment of the eye into which the composition isplaced to avoid undue damage to the tissue in such posterior segment.

The pharmacokinetics of the corticosteroid component, for example,triamcinolone acetonide, following intravitreal administration mayinvolve both the rate of drug dissolution and the rate of drug effluxvia the anterior route. For example, following a is single intravitrealinjection of a composition containing 4% (w/v) of triamcinoloneacetonide, triamcinolone acetonide concentration peaks (monitored inaqueous humor) after several days at thousands of nanograms per mL. Thispeak (C_(max)) is followed by a rapid decrease lasting about 200 hours,and ends in a slow elimination phase with a half-life of about 19 days.Patients typically require repeat dosing, for example about every threemonths.

In one embodiment of the present invention, the compositions furthercontain sustained release components, for example, polymers (in the formfor example of gels and microspheres), such as poly (D,L,-lactide) orpoly(D,L-lactide co-glycolide), in amounts effective to reduce localdiffusion rates and/or corticosteroid particle dissolution rates. Theresult is a flatter elimination rate profile with a lower C_(max) and amore prolonged therapeutic window, thereby extending the time betweenrequired injections for many patients.

Any suitable, preferably conditionally acceptable, release component maybe employed. Useful examples are set forth above. The sustained releasecomponent is preferably biodegradable or bioabsorbable in the eye sothat no residue remains over the long term. The amount of the delayedrelease component included may very over a relatively wide rangedepending, for example, on the specific sustained release component isbeing employed, the specific release profile desired and the likefactors. Typical amounts of delayed release components, if any, includedin the present compositions are in a range of about 0.05 to 0.1 to about0.5 or about 1 or more percent (w/v) (weight of the ingredient in thetotal volume of the composition) of the composition.

The present compositions can be prepared using suitableblending/processing techniques or techniques, for example, one or moreconventional blending techniques. The preparation processing should bechosen to provide the present compositions in is forms which are usefulfor placement or injection into the posterior segments of eyes of humansor animals. In one useful embodiment a concentration corticosteroidcomponent dispersion is made by combining the corticosteroid componentwith water, and the excipient (other than the viscosity inducingcomponent) to be included in the final composition. The ingredients aremixed to disperse the corticosteroid component and then autoclaved.Alternatively, the steroid powder may be y-irradiated before addition tothe sterile carrier. The viscosity inducing component may be purchasedsterile or sterilized by conventional processing, for example, byfiltering a dilute solution followed by lyophylization to yield asterile powder. The sterile viscosity inducing component is combinedwith water to make an aqueous concentrate. Under aseptic conditions, theconcentrated corticosteroid component dispersion can be blended or mixedand added or combined as a slurry to the viscosity inducing componentconcentrate. Water is added in a quantity sufficient (q.s.) to providethe desired composition and the composition is mixed until homogenous.

Methods of using the present composition are provided and are includedwithin the scope of the present invention. In general, such methodscomprise administering a composition in accordance with the presentinvention to a posterior segment of an eye of a human or animal, therebyobtaining a desired therapeutic effect. The administering stepadvantageously comprises at least one of intravitreal injecting,subconjunctival injecting, sub-tenon injecting, retrobulbar injecting,suprachoroidal injecting and the like. A syringe apparatus including anappropriately sized needle, for example, a 27 gauge needle or a 30 gaugeneedle, can be effectively used to inject the composition with theposterior segment of an eye of a human or animal.

Ocular conditions which can be treated or addressed in accordance withthe present invention include, without limitation, the following:

Maculopathies/retinal degeneration: macular degeneration, including agerelated macular degeneration (ARMD), such as non-exudative age relatedmacular degeneration and exudative age related macular degeneration,choroidal neovascularization, retinopathy, including diabeticretinopathy, acute and chronic macular neuroretinopathy, central serouschorioretinopathy, and macular edema, including cystoid macular edema,and diabetic macular edema. Uveitis/retinitis/choroiditis: acutemultifocal placoid pigment epitheliopathy, Behcet's disease, birdshotretinochoroidopathy, infectious (syphilis, lyme, tuberculosis,toxoplasmosis), uveitis, including intermediate uveitis (pars planitis)and anterior uveitis, multifocal choroiditis, multiple evanescent whitedot syndrome (MEWDS), ocular sarcoidosis, posterior scleritis,serpignous choroiditis, subretinal fibrosis, uveitis syndrome, andVogt-Koyanagi-Harada syndrome. Vascular diseases/exudative diseases:retinal arterial occlusive disease, central retinal vein occlusion,disseminated intravascular coagulopathy, branch retinal vein occlusion,hypertensive fundus changes, ocular ischemic syndrome, retinal arterialmicroaneurysms, Coat's disease, parafoveal telangiectasis, hemi-retinalvein occlusion, papillophlebitis, central retinal artery occlusion,branch retinal artery occlusion, carotid artery disease (CAD), frostedbranch angitis, sickle cell retinopathy and other hemoglobinopathies,angioid streaks, familial exudative vitreoretinopathy, Eales disease.Traumatic/surgical: sympathetic ophthalmia, uveitic retinal disease,retinal detachment, trauma, laser, PDT, photocoagulation, hypoperfusionduring surgery, radiation retinopathy, bone marrow transplantretinopathy. Proliferative disorders: proliferative vitreal retinopathyand epiretinal membranes, proliferative diabetic retinopathy. Infectiousdisorders: ocular histoplasmosis, ocular toxocariasis, presumed ocularhistoplasmosis syndrome (POHS), endophthalmitis, toxoplasmosis, retinaldiseases associated with HIV infection, choroidal disease associatedwith HIV infection, uveitic disease associated with HIV Infection, viralretinitis, acute retinal necrosis, progressive outer retinal necrosis,fungal retinal diseases, ocular syphilis, ocular tuberculosis, diffuseunilateral subacute neuroretinitis, and myiasis. Genetic disorders:retinitis pigmentosa, systemic disorders with associated retinaldystrophies, congenital stationary night blindness, cone dystrophies,Stargardt's disease and fundus flavimaculatus, Bests disease, patterndystrophy of the retinal pigmented epithelium, X-linked retinoschisis,Sorsby's is fundus dystrophy, benign concentric maculopathy, Bietti'scrystalline dystrophy, pseudoxanthoma elasticum. Retinal tears/holes:retinal detachment, macular hole, giant retinal tear. Tumors: retinaldisease associated with tumors, congenital hypertrophy of the RPE,posterior uveal melanoma, choroidal hemangioma, choroidal osteoma,choroidal metastasis, combined hamartoma of the retina and retinalpigmented epithelium, retinoblastoma, vasoproliferative tumors of theocular fundus, retinal astrocytoma, intraocular lymphoid tumors.Miscellaneous: punctate inner choroidopathy, acute posterior multifocalplacoid pigment epitheliopathy, myopic retinal degeneration, acuteretinal pigment epithelitis and the like.

The present methods may comprise a single injection into the posteriorsegment of an eye or may involve repeated injections, for example overperiods of time ranging from about one week or about 1 month or about 3months to about 6 months or about 1 year or longer.

EXAMPLES

The following non-limiting Examples are presented to exemplify aspectsof the present invention.

Examples 1 to 4

Four compositions are as follows: TABLE 1 Ingredient Example 1 Example 2Example 3 Example 4 Triamcinolone acetonide 2% (w/v) 2% (w/v) 4% (w/v)4% (w/v) Sodium Hyaluronate 0.05% 0.5% 0.05% 0.5% (0.6 × 10⁶ DALTONS)(w/v) (w/v) (w/v) (w/v) Sodium Phosphate 0.4% 0.4% 0.4% 0.4% (w/v) (w/v)(w/v) (w/v) Vitamin E-TPGS 0.5% 0.5% 0.0 0.0 (w/v) (w/v) γ-cyclodextrin0.5% 0.5% 0.0 0.0 (w/v) (w/v) Water for Injection q.s. q.s. q.s. q.s.Viscosity at shear rate 20 cps 500 cps 20 cps 500 cps 0.1/second

Each of these compositions is prepared as follows.

A concentrated triamcinolone acetonide dispersion is made by combiningtriamcinolone acetonide with water, Vitamin E-TPGS and γ-cyclodextrin,if any. These ingredients are mixed to disperse the triamcinoloneacetonide, and then autoclaved. The sodium hyaluronate may be purchasedas a sterile powder or sterilized by filtering a dilute solutionfollowed by lyophylization to yield a sterile powder. The sterile sodiumhyaluronate is dissolved in water to make an aqueous concentrate. Theconcentrated triamcinolone acetonide dispersion is mixed and added as aslurry to the sodium hyaluronate concentrate. Water is added q.s.(quantum sufficit, as much as suffices, in this case as much as isrequired to prepare the homogenous mixture, dispersion, gel orsuspension) and the mixture is mixed until homogenous.

Each of these compositions produced a loose flocculation oftriamcinolone acetonide that is easily re-suspended by gentle inversion.These compositions can be marketed in small volume pharmaceutical gradeglass bottles, and are found to be therapeutically effective againstmacular edema when injected intravitreally into human eyes.

Examples 5 to 7

Three compositions are as follows: TABLE 2 Ingredient Example 5 Example6 Example 7 Triamcinolone acetonide 2.0% (w/v) 4.0% (w/v) 8.0% (w/v)Sodium hyaluronate 3.0% (w/v) 2.5% (w/v) 2.0% (w/v) Sodium Phosphate0.4% (w/v) 0.4% (w/v) 0.4% (w/v) Water for Injection q.s. q.s. q.s.Viscosity at shear rate 300,000 cps 180,000 cps 100,000 cps 0.1/second

These compositions are prepared in a manner substantially analogous tothat set forth in Example 1.

The high viscosities of the compositions substantially slows theparticle sedimentation rate to an extent that no resuspension processingis necessary or required over the estimated shelf life, e.g., about 2years, of the compositions. These compositions can be marketed inprefilled syringes since they can not easily be removed by a needle andsyringe from a container. However, with the compositions in prefilledsyringes, the compositions can be effectively injected into theposterior segment of an eye of a human using a 27 gauge or a 30 gaugeneedle to provide a desired therapeutic effect in the human eye.

The compositions of Examples 5 to 7 employ or contain a sufficientconcentration of high molecular weight sodium hyaluronate so as to forma gelatinous plug or drug depot upon intravitreal injection into a humaneye. Triamcinolone acetonide particles are, in effect, trapped or heldwithin this viscous plug, so that undesirable pluming does not occur,and the risk of drug particles disadvantageously settling directly onthe retinal tissue is substantially reduced, for example, relative tousing a composition with a water-like viscosity, such as Kenalog® 40.Since sodium hyaluronate solutions are subject to dramatic shearthinning, these formulations are easily injected through 27 gauge oreven 30 gauge needles.

Examples 8 and 9

Two compositions are as follows: TABLE 3 Ingredient Example 8 Example 9Triamcinolone acetonide  2.0% (w/v)  8.0% (w/v) Sodium hyaluronate(polymeric)  2.5% (w/v)  2.3% (w/v) Sodium chloride 0.63% (w/v) 0.63%(w/v) dibasic sodium phosphate, 0.30% (w/v) 0.30% (w/v) heptahydrateMonobasic sodium phosphate, 0.04% (w/v) 0.04% (w/v) monohydrate Waterfor Injection q.s. q.s. Viscosity at shear rate 170,000 ± 200,000 ± 25%cps 0.1/second 25% cps

These compositions are prepared in a manner substantially analogous tothat set forth in Example 1.

The high viscosities of the compositions substantially slows theparticle sedimentation rate to an extent that no resuspension processingis necessary or required over the estimated shelf life, e.g., about 2years, of the compositions. These compositions can be marketed inprefilled syringes since they can not easily be is removed by a needleand syringe from a container. However, with the compositions inprefilled syringes, the compositions can be effectively injected intothe posterior segment of an eye of a human using a 27 gauge or a 30gauge needle to provide a desired therapeutic effect in the human eye.

The sodium hyaluronate powders used in these compositions (as well as inthe other compositions identified in the Examples herein) have watercontents in a range of about 4% to about 20%, preferably about 4% toabout 8%, by weight. Differences in the average molecular weight of thehyaluronate used can result in variation in the viscosity ofcompositions in accordance with the present invention which have thesame nominal chemical make-ups. Thus, the viscosities indicated hereinshould be understood to be target viscosities, with the compositionbeing acceptable for use if the actual viscosity of the composition iswithin plus or minus (±) about 25% or about 30% or about 35% of thetarget viscosity.

Because each of the compositions set forth in the Examples has a densityof about 1 gm/ml, the percentages set forth herein as being based onweight per volume (w/v) can also be considered as being based on weightper weight (w/w).

The compositions of Examples 8 and 9 employ or contain a sufficientconcentration of high molecular weight (i.e. polymeric) sodiumhyaluronate so as to form a gelatinous plug or drug depot uponintravitreal injection into a human eye. Preferably the averagemolecular weight of the hyaluronate used is less than about 2 million,and more preferably the average molecular weight of the hyaluronate usedis between about 1.3 million and 1.6 million. The triamcinoloneacetonide particles are, in effect, trapped or held within this viscousplug of hyaluronate, so that undesirable pluming does not occur uponintravitreal injection of the formulation. Thus, the risk of drugparticles disadvantageously settling directly on the retinal tissue issubstantially reduced, for example, relative to using a composition witha water-like viscosity, such as Kenalog® 40. Since sodium hyaluronatesolutions are subject to dramatic shear thinning, these formulations areeasily injected through 27 gauge or even 30 gauge needles.

The most preferred viscosity range for the Example 8 and 9 formulationsis 140,000 cps to 280,000 cps at a shear rate 0.1/second at 25° C.

The triamcinolone acetonide used in the formulations set forth hereinhas the chemical name 9-Fluoro-11,21-dihydroxy-16,17-[1-methylethylidenebis(oxy)]pregna-1,4-diene-3,20-dione, and canhave the following structure

The molecular formula of triamcinolone acetonide is C₂₄H₃₁FO₆ and itsmolecular weight is 434.49. The solubility of triamcinolone acetonide inwater is about 25.4 μL/mL.

The Examples 8 and 9 formulations are prepared as sterile products of auniform, opaque white dispersion of microfine triamcinolone acetonideparticles suspended in a hyaluronate-based polymeric hydrogel, intendedfor intravitreal injection.

The Examples 8 and 9 formulations can be used top treat, for example,macular edema in patients with diabetes, central retinal vein occlusion,and branch retinal vein occlusion. Notable the Examples 8 and 9formulations are formulated using only excipients that are fullycompatible (i.e. non-toxic) to the eye, particularly to the retina. TheExamples 8 and 9 formulations (2% (w/w) and 8% (w/w) triamcinoloneacetonide, respectively) are buffered at physiological pH with a lowconcentration of sodium phosphate salts; rendered isotonic with sodiumchloride, and use Water for Injection, USP, as the vehicle.

A target dosage of 1 mg of the triamcinolone acetonide active agent canbe delivered in a 50 mg (approximately 48 μL) injection of the Example82% (w/w) triamcinolone acetonide gel suspension formulation. A targetdosage of 4 mg of the triamcinolone acetonide active agent can bedelivered in a 50 mg (approximately 48 μL) injection of the Example 98%(w/w) triamcinolone acetonide gel suspension formulations.

As noted, the triamcinolone present in our formulations does notrapidly, or even slowly, settle out from or precipitate from theformulations. Significantly our Example 8 and 9 formulations have ashelf life of at least two years, meaning that these formulations can beleft standing (without agitation) for up to about two years beforeadministration to an eye, and after two years the same formulations canstill provide a consistent and accurate dose of triamcinolone uponinjection to the formulation to an eye. For example, upon preparation(as set froth in Example 15), 50 μL of our 8% formulation provides 4 mgof triamcinolone acetonide, and if left standing for up to about 2 years50 μL of our 8% formulation stills provides 4 mg±15% of triamcinoloneacetonide, thereby meeting the U.S.P. definition of consistent dosageafter storage.

As noted, the composition of triamcinolone 2% injectable gel suspension(Example 8) is triamcinolone 2.0% (w/w), sodium hyaluronate, sodiumchloride, dibasic sodium phosphate (heptahydrate), monobasic sodiumphosphate (monohydrate), and water for injection.). The composition oftriamcinolone 8% injectable gel suspension (Example 9) is triamcinolone8.0% (w/w), sodium hyaluronate, sodium chloride, dibasic sodiumphosphate (heptahydrate), monobasic sodium phosphate (monohydrate), andwater for injection.

The triamcinolone acetonide injectable gel suspension we have inventedis a viscous suspension of triamcinolone acetonide formulated atconcentrations of 8% and 2% with sodium hyaluronate, sodium chloride,dibasic sodium phosphate (heptahydrate), monobasic sodium phosphate(monohydrate), and water for injection (i.e. the formulations ofExamples 8 and 9 respectively). The suspensions are prepared to havephysiologic pH, and to be isotonic, and preservative-free. The Examples8 and 9 suspensions can be supplied in single-use glass syringes withfixed 27 gauge needles. The syringes are overfilled to 0.17-0.18 mL, andcalibrated to deliver 0.05 mL when primed to a black or blue mark on thebarrel of the syringe to thereby provide the 2% and 8% suspensions todeliver 1 mg and 4 mg of triamcinolone, respectively (the pre-filledsyringes are made by Allergan, Inc., Irvine, Calif.). These syringeshave a shelf life of at least about two years when stored at 2-8° C.

Example 10 Ocular and Systemic Pharmacokinetics of a 4% (4 mg)Triamcinolone Acetonide Gel Suspension Formulation upon IntravitrealInjection

An experiment was carried out to evaluate the intraocular and systemicpharmacokinetics of triamcinolone acetonide gel suspensions (TAA_(gs))following intravitreal administration. The formulations used were: (1)4% w/v (40 mg/mL) triamcinolone acetonide formulated as a high viscosityborate-buffered 2.5% (w/w) hyaluronic acid suspension, and; (2) 16% w/v(160 mg/mL) triamcinolone acetonide formulated as a high viscosityborate-buffered 2.5% (w/w). 100 μL of each formulation was injected intoseparate rabbit eyes using a 25-gauge needle syringe to provide 4 mg or16 mg of triamcinolone actinide, respectively. Except as noted theformulations used in this Example 10 were the same as the Example 8 and9 formulations. For example, the same type of sodium hyaluronate wasused in these Example 10 formulations.

Following a single intravitreal injection (New Zealand albino rabbits)of 100 μL of the 4% w/v triamcinolone acetonide formulation (4 mgtriamcinolone acetonide), aqueous humor, vitreous humor, retina andplasma were collected on days 1, 3, 10, 17, 31 and 45 and analyzed fortriamcinolone acetonide by liquid chromatography tandem massspectrometry. In vitreous humor, the maximal triamcinolone acetonideconcentration (C_(max)) was 385 μg/g on Day 10. The relatively constantconcentrations (i.e. sustained release) of triamcinolone acetonide wereobserved from Day 1 to Day 45. (Tables 4 and 5) Therefore, the TAA_(gs)formulation delivers a relatively stable concentration (i.e.approximately zero-order release kinetics) of triamcinolone acetonide tothe retina over at least 45-day period following single intravitrealinjection.

Table 4 also shows that the ratio of the amount of triamcinoloneacetonide present in the vitreous to the amount of triamcinoloneacetonide present in the aqueous chamber can be greater than 1000:1 atall time points.

Table 5 shows that ratio of the total amount of triamcinolone acetonidepresent in the vitreous over the 45 day study period to the total amountof triamcinolone acetonide present in the aqueous humor over the 45 daystudy period can be greater than about 5,000:1. TABLE 4 Triamcinoloneacetonide concentration in aqueous humor, retina and vitreous humorafter a single intravitreal injection of a 4% triamcinolone acetonideformulation in albino rabbits Triamcinolone Acetonide (μg/mL or μg/g)Timepoint (Day) Aqueous Humor Vitreous Humor 1 0.319 382 3 0.200 335 100.052 385 17 0.033 338 31 0.014 185 45 0.011 222

TABLE 5 Pharmacokinetic parameters of triamcinolone acetonide in oculartissues after a single intravitreal injection of 4% triamcinoloneacetonide formulation in albino rabbits C_(max) AUC_(0-45day) Treatment(μg/mL or μg/g) (μg · day/mL or μg · day/g) Vitreous Humor 4%Triamcinolone 385 12500 Acetonide Injectable Aqueous Humor 4%Triamcinolone 0.319 2.36 Acetonide Injectable

Following intravitreal administration of the 4% TAA_(gs) formulation inalbino rabbits, triamcinolone acetonide was absorbed into the systemiccirculation with mean plasma C_(max) of 15.8 ng/mL at 1 day postdose.Between days 2 and 45, plasma levels drop to 7 and 1 ng/mL,respectively. Thus, our the triamcinolone acetonide gel suspensionformulations are free of excipients with known ocular toxicity, andthrough sustained release from the gel delivers prolonged levels oftriamcinolone acetonide to the vitreous and retina.

Example 11 Triamcinolone Gel Suspensions to Treat Ocular Conditions

Introduction

As set forth herein, we have invented triamcinolone acetonide gelsuspensions (TAA_(gs)) and their use to treat various ocular conditions,including macular edema, such as macular edema associated with diabetesand/or a retinal vein occlusion, (branch or central), and to maintain orto improve visual acuity. Our TAA_(gs) formulations can contain apolymeric hyaluronic acid.

The blood-aqueous barrier (“BAB”) is a membrane of the capillary bed ofthe ciliary body of the eye that influences or controls two-way transferof fluids between the aqueous chamber of the eye and the blood. The BABacts as an anatomical mechanism to reduce or prevent exchange ofmaterials between the chambers of the eye and the blood.

The blood-retinal barrier (“BRB”) is composed of specializednonfenestrated tightly-joined (tight junction) retinal epithelium andadjacent retinal blood vessel endothelium cells that forming a transportbarrier for certain substances between the retinal capillaries and theretinal tissue. BRB breakdown is symptomatic of various retinal ocularconditions, including reduced visual acuity, macular edema, maculadegeneration, retinal swelling, and other retinopathies, includingdiabetic retinopathy.

This experiment was designed to assess efficacy and duration of actionof particular TAA_(gs) polymeric hyaluronic acid formulations injectedintravitreally to treat break down (deterioration) of the blood-aqueousbarrier (“BAB”) and of the blood-retinal barrier (“BRB”) in mammal eyes.Generally, a reduced BRB breakdown is a is desirable condition or state,as it indicates a stabilized or more normal or more healthy retina(tightened barrier). On the other hand, where in a model system a BABbreakdown is induced, it is considered a positive or beneficial resultif upon intravitreal administration of a steroid, such as acorticosteroid or an anti-inflammatory steroid into an eye with BABbreakdown, an improvement of the BAB breakdown is not observed. Failureof BAB breakdown to be reduced or repaired is an indication that thesteroid intravitreally administered has not in significant quantity madeit's way (i.e. by diffusion and/or by an active transport mechanism) tothe aqueous (or anterior) chamber (“AC”) of the eye. It is known that ACpresence of various steroids can cause increased intraocular (i.e.aqueous humor) pressure (elevated IOP is symptomatic of glaucoma) and/orcataract generation.

SUMMARY

The experiment was carried out using intravitreal injection of either a1 mg or 4 mg triamcinolone acetonide gel suspension (TAA_(gs)) (theExample 8 and 9 formulations, respectively) in a rabbit model ofVEGF-mediated blood-aqueous barrier (BAB) and blood-retinal barrier(BRB) breakdown. The model system used is set forth in Edelman et al.,Corticosteroids inhibit VEGF-induced vascular leakage in a rabbit modelof blood-retinal and blood-aqueous barrier breakdown, Exp Eye Res 2005February; 80(2):249-58, although instead of intravitreal injection of atriamcinolone acetonide saline suspension, the formulation of Examples 8and 9 above were used in this experiment.

BAB breakdown was measured by anterior chamber fluorophotometry. BRBbreakdown was measured by vitreal fluorophotometry and subjectivegrading of fluorescein angiograms. In addition, VEGF-induced changes invessel caliber and tortuosity (AVC-T) were assessed by subjectivescoring of fundus images. The equipment and procedures used to obtainanterior chamber fluorophotometry, vitreal fluorophotometry, fluoresceinangiograms, and fundus images were as set forth in Edelman (2005) supra.

The results obtained in this experiment can be summarized as follows:

1. intravitreal 1 mg TAA_(gs) had no effect on VEGF-induced BAB at anytime point as compared to control eyes.

2. intravitreal 1 mg TAA_(gs) significantly inhibited VEGF-induced BRBand AVC-T through at least 6 weeks.

3. intravitreal 4 mg TAA_(gs) did not significantly inhibit VEGF-inducedBAB breakdown at 10, 22, and 30 weeks.

4. intravitreal 4 mg TAA_(gs) significantly blocked VEGF-inducedangiographic BRB breakdown for at least about 14 weeks,fluorophotometric BRB breakdown for at least about 22 weeks, and ΔVC-Tfor at least about 14 weeks, and in at least some rabbit eyes for up toat least about 30 weeks.

Methods

Female Dutch Belt rabbits (5 to 6 months old) were randomly assigned toa no treatment group (control; n=12 eyes), to a group to receiveintravitreal injection of 1 mg TAA_(gs) (n=8 eyes), or to a group toreceive intravitreal injection of 4 mg TAA_(gs) (n=10 eyes). 50 μL ofthe 2% or 8% (Example 8 and Example 9 formulations respectively)TAA_(gs) formulations were intravitreally injected into eyes of thelater two groups on Day 1. Since the VEGF responses are transient andreturn to baseline by one week (See Edelman et al.(2005), supra), theTAA_(gs) duration of action was determined by injecting VEGFintravitreally at multiple times points over a 10 week for 1 mg TAA_(gs)and over a 30 week for the 4 mg TAA_(gs). Thus, the VEGF was injectedintravitreally at 2 weeks, 6 weeks and 10 weeks after study initiationfor the 1 mg TAA_(gs) study rabbits. The VEGF was injectedintravitreally at 2 weeks, 6 weeks and 10 weeks, 14 weeks, 22 weeks, and30 weeks after study initiation for the 4 mg TAA_(gs) is study rabbits.

Drug (FAA_(gs)) Injection

General anesthesia was initiated by isoflurane inhalation and the ocularsurface was anesthetized with 1-2 drops of 1% proparacaine. Rabbits werethen placed on a heated pad, covered with a sterile drape, and both eyeswere treated with Betadine for 30 seconds and rinsed with sterilesaline. 50 μL of the 1 mg or 4 mg TAA_(gs) formulations (the Example 8and 9 formulations, respectively) were administered via their originalglass syringes and 27 gauge needle, and each syringe was calibrated tothe blue line prior to injection). The syringe needle was inserted about3 mm posterior to the limbus and aimed inferior and posterior. Afterinjection, the needle was removed and the eye was checked for leakage.

Rabbit Model of VEGF-Induced Vasculopathologies

The Edelman (2005) A model of BRB and BAB breakdown was used todetermine the pharmacologic duration of action after intravitrealinjection of 1 and 4 mg TAA_(gs). Rabbits were placed on a heated pad,covered with a sterile drape, and 500 ng of recombinant human vascularendothelial growth factor (165 amino acid variant; VEGF₁₆₅, obtainedfrom R & D Systems, Minneapolis, Minn.) in 50 μL sterile phosphatebuffered saline was injected intravitreally into all eyes via a 27Gneedle.

Forty-Eight hours after VEGF injection, eyes were dilated with 10%phenylephrine HCl and 1% cyclopentolate HCl. Anesthesia was induced viasubcutaneous injection of 50 mg/kg ketamine and 10 mg/kg xylazine. Onceanesthetized, the rabbit fundus was visualized with a Zeiss retinalcamera and fundus images were obtained and stored on a personalcomputer. Sodium fluorescein was administered intravenously (11.75mg/kg) and late phase angiograms were obtained after 5-10 min. Fiftyminutes after fluorescein injection BRB and BAB integrity were measuredusing scanning ocular fluorophotometry (Fluorotron Master).

Fundus images were graded on a scale of 1 (normal) to 5 (maximal bloodvessel dilation and tortuosity) by three masked observers. Retinalfluorescein leakage was scored from angiograms read by masked observerson a scale of 1 (no fluorescein leakage=normal) to 5 (maximumfluorescein leakage).

Angiogram and fundus image scores were compared with an unpairednon-parametric Wilcoxon Rank Sum/Mann-Whitney U-Test. Fluorophotometricmeasurements (area under the curve) were analyzed with a two tailedStudents t-test. P-values≦0.05 are determined to be significant.

Results

2% TAA_(gs): 1 mg dose

1. Effect on blood-retinal barrier (BRB) breakdown. Subjective gradingof angiograms (FIG. 1) or vitreal fluorophotometry (FIG. 2) shows thatVEGF-induced BRB breakdown was suppressed in eyes treated with 1 mgTAA_(gs) through at least about six weeks.

2. Effect on changes in retinal vessel caliber-tortuosity (ΔVC-T).Subjective grading of fundus images (FIG. 3) shows that VEGF-inducedΔVC-T was suppressed in eyes treated with 1 mg TAA_(gs) through at leastabout six weeks.

3. Effect on blood-aqueous barrier (BAB) breakdown. Anterior chamberfluorophotometry shows that the extent of VEGF-induced BAB breakdown wasnot suppressed in rabbit eyes treated with the 1 mg TAA_(gs) for atleast at about 10 weeks (FIG. 4).

8% TAA_(gs): 4 mg Dose

1. Effect on BRB breakdown. Subjective grading of angiograms (FIG. 1) oris vitreal fluorophotometry (FIG. 2) shows that VEGF-induced BRBbreakdown was suppressed in eyes treated with 4 mg TAA_(gs) for betweenabout fourteen weeks (FIG. 1) and twenty weeks (FIG. 2).

2. Effect on ΔVC-T. Subjective grading of fundus images (FIG. 3) showsthat VEGF-induced ΔVC-T was clearly suppressed in all eyes treated with4 mg TAA_(gs) for at least fourteen weeks, and for some rabbits throughtwenty two to thirty weeks (210 days or about 7.5 months).

3. Effect on BAB breakdown. Anterior chamber fluorophotometry (FIG. 4)shows that the extent of VEGF-induced BAB breakdown was notsignificantly suppressed at 10, 22, and 30 weeks.

These results showed significant inhibition of VEGF-induced BRBresponses for at least six weeks with intravitreal 1 mg TAA_(gs) (FIGS.1-3), and for at least 30 weeks with intravitreal 4 mg TAA_(gs) (FIG.3). Note that FIG. 5 (a negative image of a photograph of the eye of arabbit in this Example 11 thirty weeks after intravitreal injection of50 μL of the 4 mg TAA_(gs) formulation) shows that our TAA_(gs).formulation can remain intact in the vitreous for a prolonged period. InFIG. 5 item A is the intact, single object (bolus) intravitreal 4 mg, 50μL TAA gel suspension 30 weeks after intravitreal injection. B is thevitreous chamber and C is a light reflection artifact.

Thus, based upon a demonstrated therapeutic effect for as long as thirtyweeks after intravitreal injection of a TAA_(gs) formulation, whichTAA_(gs) which remains intact in the vitreous for the same period, ourTAA_(gs) formulation can be characterized as a sustained release,biocompatible, biodegradable implant.

Thus, the results from this experiment demonstrate that intravitrealadministration of a TAA_(gs) formulation can be used to treat a retinaldisease or condition (such as a retinal disease or condition whichincludes BRB breakdown or deterioration) with no or is little diffusionof drug to the anterior chamber (as determined for example by theExample 10 data, and by the lack of or of a reduced effect on BABbreakdown set forth in this Example 11). It can therefore be concludedthat our TAA_(gs) formulations can be used to advantageously treat aretinal disease or condition with, for example, little or no IOPelevation (with reduced incidence of glaucoma therefore) and with no orlittle inducement of cataract formation or intraocular inflammation.

Our TAA_(gs) formulations have numerous novel and advantageouscharacteristics making them well suited for the treatment of ocularconditions, such as posterior ocular conditions, such as macular edema,such as diabetic macula edema. For example our TAA_(gs) formulation (forexample the Examples 8 and 9 formulations) do not contain anypreservatives or excipients such as an alcohol (such as a benzylalcohol) or a polysorbate (such as a polysorbate 80). Thus our TAA_(gs)formulations have a reduced retinal toxicity.

Additionally, our TAA_(gs) formulations have superior depot and releasecharacteristics. Intravitreal injection of an aqueous (i.e. in saline)solution of a triamcinolone provides active agent which quickly (in amatter of hours) diffuses out of the retina. Our TAA_(gs) formulationshave a longer duration of intravitreal therapeutic activity becausetherapeutic amounts of the triamcinolone can diffuse out of the gel overa period of thirty weeks or more. Thus, use of a suspending agent suchas a polymeric hyaluronate can provide the consistency permittingsubstantially zero order kinetics release of the triamcinolone form thehyaluronate, proving thereby both an extended duration of effect of thetriamcinolone and reduced levels and therefore a reduced effect of thetriamcinolone upon the anterior chamber of the eye and a reducedsystemic exposure to the active agent.

Our invention comprises triamcinolone acetonide injectable gelsuspensions formulated viscous suspensions of triamcinolone acetonide atconcentrations of, for example, 8% and 2% with sodium hyaluronate,sodium chloride, dibasic sodium phosphate (heptahydrate), monobasicsodium phosphate (monohydrate), and water for injection. Thetriamcinolone acetonide injectable gel suspensions are preferably atphysiologic pH, isotonic, and preservative-free. Triamcinolone acetonideinjectable gel suspensions within the scope of our invention can besupplied in single-use glass syringes with fixed 27 gauge needles. Thesyringes can be overfilled to 0.17-0.18 mL, and calibrated to deliver0.05 mL when primed to a black mark on the barrel of the syringe tothereby deliver, for example, 2% and 8% suspensions of 1 mg and 4 mg oftriamcinolone, respectively. Our triamcinolone acetonide injectable gelsuspensions can be defined as implants which upon injection (i.e.implantation) into the vitreous provided sustained release (i.e. over aperiod of up to seven months or longer) from the compact gel bolusinjected.

Our triamcinolone acetonide injectable gel suspensions are preferablynot used as visualizing agents, for example in conjunction with avitrectomy (see eg U.S. Pat. No. 6,395,294) because the viscous, gelnature of our formulations prevents them for rapidly spreading outwithin the vitreous, as is required for a vitreal visualization agent(such as for example triptan vision blue, or water or saline basedtriamcinolone solutions or formulation, such as Kenalog®). A lowermolecular weight hyaluronate with triamcinolone acetonide can be usedfor visualization (for example with a viscosity at a shear rate of about0.1/second of less than about 90,000 cps, such as for example about1,000 to 10,000 cps), whereas the higher molecular weight hyaluronate ofExamples 8 and 9 are preferred for use as in situ forming vitreousimplants.

Example 12 Treatment of Macular Edema with Intravitreal TriamcinoloneAcetonide Suspension

A 64 year old obese female patient with symptoms of diabetes presentswith vision loss due to macula edema with central retinal vein occlusionand/or branch retinal vein occlusion. She receives intravitrealinjection of 4 mg of a high viscosity triamcinolone acetonide (polymerichyaluronate based) suspension, such as the Example 9 formulation.

Twelve months after injection she demonstrates an improved bestcorrected visual acuity of fifteen or more letters from baseline asdetermined using the Early Treatment of Diabetic Retinopathy Study(ETDRS) visual acuity chart.

Example 13 Treatment of a Posterior Ocular Condition with IntravitrealTriamcinolone Acetonide Suspension

Patients with a posterior ocular condition (such as a macular edema,uveitis, or macular degeneration) can be treated by intravitrealinjection of 1 mg or 4 mg of a high viscosity triamcinolone acetonidegel (polymeric hyaluronate based) suspension, such as the Example 8 orExample 9 formulation. Alternately, the formulation can be administeredby subconjunctival injection to treat the posterior ocular condition.These patients can demonstrate twelve months after injection an improvedbest corrected visual acuity of fifteen or more letters from baseline asdetermined using the Early Treatment of Diabetic Retinopathy Study(ETDRS) visual acuity chart.

In clinical studies being carried out for the treatment of macula edema,participated in, or supervised by the inventors or their colleagues overone thousands patients have received intravitreal injection of theExample 8 or Example 9 formulations. Yet the incidence of asepticendophthalmitis in these numerous patients has been 0%. This is strikingwhen one notes that the incidence of endophthalmitis upon intravitrealinjection of Kenalog is about 1% to 2%.

Thus, it is important to note that the desired therapeutic result(maintained or improved vision) can be obtained with little or noincidence of intraocular inflammation. Without wishing to be bound bytheory we can postulate reasons for this exceptional result. Macrophagesare involved with the removal of particulate material from the bodythrough phagocytosis. However, particles of large morphology andirregular is geometry can be toxic to macrophages and lead to celldeath. The death of macrophages can lead to release of pro-inflammatorycytokines that cause both acute and chronic inflammation. Clinicalexamples of toxicity from particles include gouty arthritis, where uratecrystals that range from 5 to 20 microns cause a debilitating arthritis.Helliwell P., Use of an objective measure of articular stiffness torecord changes in fingerjoints after intra-articular injection ofcorticosteroid, Ann Rheum Dis 1997; 56:71-73. Macrophages are injuredwhen phagocytosing the urate crystals and this initiates theinflammatory response. When patients are treated with medication thatreduces macrophage activity, such as colchicine, this leads to adramatic improvement in the arthritis. Another example of jointinflammation related to particles is ‘crystal-induced synovitis,’ where1-2% of patients that receive intra-articular injections of Lederspan,Kenalog, or other corticosteroid depot formulation, develop apost-injection exacerbation of the joint inflammation. McCarty D., etal., Inflammatory reaction after intrasynovial injection ofmicrocrystalline adrenocorticosteroid esters, Arthritis and Rheumatism,7(4); 359-367 (1964). The particles in these formulations, which are onthe average over 10 microns and have irregular morphology, are verysimilar to the urate crystals in joint of patients with gout.Significantly, in our formulations the triamcinolone particles(crystals) are not available to and/or are substantially ignored bymacrophages due to the aggregation (suspension) of the triamcinoloneparticles in the high molecular weight hyaluronate used in ourformulations. The fact that our triamcinolone formulations are in situforming implants can also limit the exposure of whole or individualtriamcinolone crystals to sensitive ocular tissues, concomitantlythereby limiting macrophage activation and hence also limiting orpreventing an intraocular inflammatory response. It is important to notethat with our formulation the particular high viscosity hyaluronic acidpolymer chosen maintains the triamcinolone crystals in a collectivematrix that acts as a sustained-release reservoir which decrease theneed for frequent repeat injections. Thus, our formulation forms acohesive agglomerate upon intravitreal injection. The reduced surfacearea of such an agglomerate facilitates provision and maintenance of alower release rate of the triamcinolone, as compared to much largersurface area saline suspension of a triamcinolone (such as Kenalog). Thecohesiveness of our formulation is exemplified by the fact that theformulation maintains its internal consistency (i.e. its shape afterinjection) for at least about 30 weeks after intravitreal injection (seeFIG. 5).

Additionally, the compositions of our invention are preferablyformulated with hyaluronic acid, a material known for itsanti-inflammatory abilities. Dea I. et al., Hyaluronic acid: a novel,double helical molecule, Science, 1973 Feb. 9; 1 79(73):560-2.).

Furthermore, the absence of preservatives and/or stabilizers (such asbenzyl alcohol and polysorbate 80) in our formulation reduces theretinal toxicity of our formulations as compared to formulations whichcontain one or more preservatives and/or stabilizers.

The combination of these five factors (lack of injury to macrophages,low availability of the triamcinolone crystal to macrophages, use of abiocompatible polymer, use of a high viscosity biocompatible polymer,and absence of preservatives and stabilizers provides an optimalophthalmic delivery system which limits the incidence of post-injectionaseptic endophthalmitis.

A preferred embodiment of our invention can be the Example 8 and 9formulations in which the average diameter of the triamcinoloneparticles present in the formulations is less than 10 microns andpreferably less than 5 microns, and additionally with a uniform(spherical) morphology. It has been shown in the pulmonary literaturethat micronized particles of corticosteroids, <10 microns, andpreferably <5 microns, are less injurious to macrophages, and have thepotential for less inflammation. (Robert A. Freitas Jr., Nanomedicine,Volume IIA: Biocompatibility, Landes Bioscience, Georgetown, Tex.,2003). Thus, preparing our formulations with a is median triamcinoloneparticle size of <5 microns and with uniform shape provides formulationwhich are even more biocompatible in the vitreous and with lesspropensity to cause intraocular inflammation.

Example 14 Six Month Ocular and Systemic Pharmacokinetics ofTriamcinolone Acetonide Following Intravitreal Injection of 2% (1 mg)and 8% (4 mg) Triamcinolone Acetonide Injectable Gel SuspensionFormulations in Rabbit Eves

An experiment was carried out to compare the ocular and systemicpharmacokinetics of triamcinolone acetonide (TA) following a singleunilateral intravitreal injection of 2% (1 mg) and 8% (4 mg) TAinjectable gel suspensions in new Zealand white rabbit eyes. Thesesuspensions are the TA formulations of Examples 8 and 9, respectively.

Seventy-two female New Zealand White rabbits were obtained from Harlan(Indianapolis, Ind.). The rabbits were specific pathogen free (SPF),17-18 weeks old and weighed 2.58-3.15 kg at the time of dosing. Theseventy-two female rabbits were intravitreally injected with one of twoTA doses (2% or 8%) and ocular and systemic pharmacokinetics monitored.Rabbits (four per group) were sacrificed on days 2, 4, 11, 32, 64, 92,121, 151 and 183 for aqueous humor (AH), vitreous humor (VH) and plasmadrug levels determined at each such time point at each of these threephysiological locations. Samples were quantified using validatedLC-MS/MS methods with assay range for TA of 0.2-20 ng/mL in plasma,1-500 ng/mL in AH and 0.4-100 pg/mL in VH.

This study was a single treatment, parallel design, with 18 treatmentgroups and non-serial samples collected from each animal, as shown byTable 6. TABLE 6 Study Design Euthanasia and Number of Treatment (RightEye Only) Necropsy Group Rabbits (Day 1 = Day of intravitreal injection)TA Dosed (Day) A 4 2% (1 mg) Triamcinolone Gel Suspension 1 mg 2 B 4 2%(1 mg) Triamcinolone Gel Suspension 1 mg 4 C 4 2% (1 mg) TriamcinoloneGel Suspension 1 mg 11 D 4 2% (1 mg) Triamcinolone Gel Suspension 1 mg32 E 4 2% (1 mg) Triamcinolone Gel Suspension 1 mg 64 F 4 2% (1 mg)Triamcinolone Gel Suspension 1 mg 92 G 4 2% (1 mg) Triamcinolone GelSuspension 1 mg 121 H 4 2% (1 mg) Triamcinolone Gel Suspension 1 mg 151I 4 2% (1 mg) Triamcinolone Gel Suspension 1 mg 183 J 4 8% (4 mg)Triamcinolone Gel Suspension 4 mg 2 K 4 8% (4 mg) Triamcinolone GelSuspension 4 mg 4 L 4 8% (4 mg) Triamcinolone Gel Suspension 4 mg 11 M 48% (4 mg) Triamcinolone Gel Suspension 4 mg 32 N 4 8% (4 mg)Triamcinolone Gel Suspension 4 mg 64 O 4 8% (4 mg) Triamcinolone GelSuspension 4 mg 92 P 4 8% (4 mg) Triamcinolone Gel Suspension 4 mg 121 Q4 8% (4 mg) Triamcinolone Gel Suspension 4 mg 151 R 4 8% (4 mg)Triamcinolone Gel Suspension 4 mg 183

The seventy-two rabbits received a single unilateral (right eye)intravitreal injection of either 2% (1 mg) or 8% (4 mg) TA gelsuspension. On day 1 each rabbit received an intravitreal injection intothe midvitreous region through the dorsotemporal quadrant of the righteye, approximately 2-3 mm posterior to the limbus. For each injection,the needle of a pre-filled syringe (2% and 8% TA pre-filled syringes)was introduced through the dorsotemporal quadrant of the eye,approximately 2-3 mm posterior to the limbus, with the bevel of theneedle directed downward and posteriorly to avoid the lens. 50 μL ofeither the 2% or 8% formulation was injected in a single bolus at alocation roughly in the center of the vitreous.

There were no drug-related effects on body weight and mortality.Following a single intravitreal injection of either 2 or 8% TA gelsuspension, TA was detected in the is AH, VH and plasma at the earliesttimepoint of Day 2. No contralateral diffusion of TA to the untreatedeyes was detected in AH. The AH mean maximal concentrations (C_(max))for 2% and 8% TA gel suspension were 27.6 ng/mL (Day 2) and 29.5 ng/mL(Day 11), respectively. The AH drug levels for the 2% and 8% dose weredetectable up to Day 32 (4.15 ng/mL) and Day 151 (3.55 ng/mL),respectively. The area under the AH concentration time curve(AUC_(0-tlast)) was dose-dependent for the 2% (328 ng-day/mL) and 8%(1311 ng-day/mL) gel suspension with half-life (t_(1/2)) of 12.4 and94.1 days, respectively.

Following intravitreal injection of 2% and 8% TA gel suspension, VHconcentration of TA declined from 444 pg/g (57.6% dose remaining) at 2days postdose to 22.1 μg/g (3.4% dose remaining) by 32 days post doseand 1460 μg/g (51.2% dose remaining) at 2 days to 33 μg/g (1.3% doseremaining) by 151 days post dose, respectively. No contralateraldiffusion of TA to the untreated eyes was detected in VH at alltimepoints except for the 8% dose on Day 2 (0.306 pg/g). TheAUC_(0-tlast) for the 2% and 8% doses were 3410 pg-day/g and 68800pg-day/g, respectively. The t_(1/2) for the 2% and 8% doses were 8.57and 32.8 days, respectively. This 33 day half life is significantlygreater than the 15 day half life reported for a saline suspension of TA(such as is Kenalog) in the vitreous (Aubren (2004), supra). The 33 dayhalf life can be expected to increase significantly to a half life ofabout 50-60 days in the VH of pathological and/or vitrectomized eyes.

The plasma C_(max) (Day 2) for the 2% and 8% doses were 4.12 ng/mL and3.59 ng/mL, respectively. Plasma TA was detected for the 2 and 8% doseup to Day 11 and Day 64, respectively. The AUC_(0-tlast) for the 2% and8% doses were 18.1 ng-day/mL and 83.6 ng-day/mL, respectively. The t₁₂for the 2% and 8% doses were 3.11 and 16.2 days, respectively.

Significantly (as noted above), TA was detected in the VH for the 2% (1mg) and 8% (4 mg) TA gel suspension for up to 1 and 5 months postdose,respectively. The systemic exposure to TA following intravitrealinjection was low and is expected to be relatively safe compared tosystemic exposure of oral TA. Thus, it can be concluded that at leastour 8% TA gel suspension can release TA into the vitreous over at leasta 5 month (151 day) period, in the manner therefore of an in situforming sustained release implant.

Example 15 Method for Making Injectable Triamcinolone Acetonide GelSuspension Formulations

Preferred methods were developed for making the formulations of Examples1 to 9.

The triamcinolone formulations are made as sterile, uniform, opaquewhite gel suspensions suitable for intraocular (such as intravitreal)injection. The manufacturing process involves two main stages: 1)sterile suspension bulk compounding and 2) aseptic filling. The bulkproduct manufacture includes preparations of three separate parts,followed by aseptic combination of these three parts. The asepticfilling operation is conducted in a class 100 environment, and thesterile bulk product may be filled into pre-sterilized ready-to-usesyringes.

Micronized triamcinolone acetonide, USP, was purchased from Pfizer,Inc., Kalamazoo Mi. Typical and most useful particle sizes for this drugare 4-8 microns in diameter. Sodium hyaluronate powder was purchasedfrom Hyaluron, Woburn, Mass. Typical and most useful molecular weightsfor this polymer are 1.0 to 1.9 million Daltons. When used,SBE7-β-cyclodextrin (Captisol®) was obtained from CyDex, Inc., OverlandPark, Kans.

Part I is prepared in a main batch vessel that has capabilities of bulkheat sterilization and viscous fluid mixing. First, water for injection(WFI) at 40% of batch size is charged into the vessel and sodiumchloride is dissolved. Triamcinolone powder is then added and dispersedwith strong agitation. The suspension is heated and sterilized at above121° C. for a sufficient time period by steam passing through the jacketof the vessel. After the bulk heat cycle is completed, the suspension iscooled down to room temperature.

Part II is prepared in an open vessel equipped with a top entering,variable speed mixer. First, WFI at 10% of batch size is charged intothe vessel. Sodium phosphate salts and, optionally, a β-cyclodextrinderivative is added and dissolved. If necessary, the pH of the solutionis adjusted with 1 N sodium hydroxide and/or 1 N hydrochloric acid. Whena beta cyclodextrin is used in the formulation is can be dissolved alongwith the phosphate salts in this part II.

Part III is prepared in a Class 100 environment through a series ofaseptic procedures. First, sodium hyaluronate is dissolved in WFI atdilute concentration, e.g., 0.2% w/w. The solution is sterile-filteredand sodium hyaluronate powder is recovered through bulk lyophilization.Finally, the sodium hyaluronate powder is reconstituted with sterile WFIat 50% of batch size.

Sterile bulk suspension is compounded by aseptically combining (mixing)the three parts. First, Part II solution is filtered into sterile Part Iin the main batch vessel using a 0.2 micron sterilizing grade filter.Part III is then aseptically transferred into the main batch vessel.Finally, the bulk is blended (mixed) under low shear conditions toachieve uniformity. The final bulk suspension is held in a controlledarea before aseptic filling.

Aseptic filling operations are performed in a Class 100 environment.Sterile bulk suspension is first filtered through a clarification screeninto a sterile holding container. The bulk is then transferred to thefilling machine and filled into pre-sterilized syringes. The filledunits are transferred to the packaging area for application oftamper-evident seals, labeling and cartoning.

The pharmaceutical manufacturing process of this Example 15 for makingtriamcinolone sterile suspensions is illustrated by the FIG. 6 processflow chart.

Although not shown in FIG. 6, after Part III has been made (and beforethe lyophilization step is applied to Part III), Part III can be heatedat between about 120° C. and about 130° C. for between about 25-35minutes. Doing so both sterilizes the hyaluronate and can reduce theinitial 1 million to 1.9 million Daltons molecular weight of thehyaluronate used in our formulation by about 20% to about 30% (i.e. tobetween about 0.7 million to about 1.3 million Daltons), therebypermitting use of a higher (i.e. 30 gauge) gauge injection needle.

Example 16 Low Immunogenicity, Stable Intraocular TriamcinoloneCompositions

We carried out further experiments with the formulation of Example 9, apharmaceutical composition comprising 8% triamcinolone acetonide inpolymeric hyaluronic acid, referred to herein by the trade name Trivarisor Trivaris 8%. The findings set forth herein apply as well to theExample 8 formulation (Trivaris 2%). We confirmed the low immunogenicityor anti-inflammatory nature of Trivaris and determined that uponintraocular administration substantially all the Trivaris triamcinoloneacetonide particles are embedded within the polymeric matrix of thehyaluronic acid and that Trivaris is storage stable.

Sterile endophthalmitis is an inflammatory response that can exacerbatemacular edema, cause retinal detachment, and lead to vision loss.Sterile endophthalmitis can occur upon intravitreal injections of prior,known triamcinolone acetonide (TA) formulations. For example, sterileendophthalmitis has been reported with aqueous (low viscosity) TAformulations, such as Kenalog-40, that contain the preservative benzylalcohol. Significantly, sterile endophthalmitis has also been reportedwith intravitreal injection of preservative free TA formulations so thepresence of the preservative in Kenalog-40 may not be the primary causeof the cases of sterile endophthalmitis it can cause.

A major factor associated with the inflammatory reaction characteristicof sterile endophthalmitis can be the drug particle burden in thevitreous cavity, as evidenced by the plume effect, which occurs uponintravitreal injection of an aqueous (low viscosity) TA formulation.Thus, individual drug particles are recognized by macrophages residentin the vitreous as they attempt to phagocytose free floating drugparticles. Phagocytosis leads to cytokine release and both neutrophilsand macrophages are thereby recruited to the vitreous cavity. Theenormous numbers of indigestible drug particles released into thevitreous by a aqueous TA formulation (with or without a preservative)can be lethal to macrophages and neutrophils, causing these cells dieand release lysosomal contents, oxidative enzymes, and moreproinflammatory cytokines. This results in an acceleration of theinflammatory reaction and hence the clinical manifestations of sterileendophthalmitis.

Due to their higher density triamcinolone acetonide drug particlesinjected into the is vitreous agglomerate into consolidated drug depotswithin the first week following intravitreal injection. Therefore, therisk of sterile endophthalmitis occurring is generally within the 48hour period after intravitreal injection as this is the time when themacrophages have greatest access to the still free floating, individualdrug particles.

Three lots of Kenalog-40 were examined (see FIG. 7) and it wasdetermined that the TA particles in Kenalog can be as large as 80microns, with high particles size variability. The heterogeneouspopulation of drug particles in Kenalog-40 ranging in size from about 2to about 80 microns can be injurious to phagocytes since larger andirregularly shaped drug particles are poorly ingested by such cellsresulting in phagocyte cell death. This toxic inflammatory reaction tocorticosteroid crystals has also been observed following intra-articularinjections where an inflammatory joint reaction occurs within 48 hoursafter injection is called crystal synovitis. Other more remote causes ofsterile endophthalmitis with use of intravitreal corticosteroidformulations include the presence of endotoxins, extraneous particlesand/or excipients in the formulation and the formulation having a pHless than 5 or greater than pH 8.

The particles size distribution of four lots of Trivaris was alsoexamined. As shown by FIGS. 8A to 8D, the median TA particles size inTrivaris was between about 4 microns and 5 microns and 90% of the TAparticles in Trivaris had a diameter of 10 microns or less. FIG. 8 alsoshows that about 40% of the Trivaris TA particles had a diameter betweenabout 4 microns and about 8 microns and that about 60% of the TrivarisTA particles had a diameter between about 3.5 microns and about 9microns.

The TA particle size distribution data in FIGS. 7 and 8 was obtained bylight scattering using a Horiba LA 300 instrument. The line graph inFIGS. 8A, B, C and 8D shows the cummulative TA particle size % (areaunder the curve) (right hand side Y axis). Trivaris is a viscous TAformulation in which the TA drug particles are embedded in and coated bythe polymeric matrix of the hyaluronic acid (HA) to thereby form aviscoelastic hydrogel with a viscosity of between about 130 k and about300 k centipoises (cps) at a shear rate of about 0.1/second at 25° C.Significantly, the TA drug particle sizes in Trivaris are deliberatelyuniform in distribution with a median particle size ranging from about 4to about 6 microns. This hydrogel formulation of Trivaris can beinjected through a hypodermic (syringe) needle having a needle gauge assmall as 33 gauge.

The HA in Trivaris creates a physical barrier to free movement of theembedded TA drug particles, thereby reducing the potential for freefloating TA particle exposure in the vitreous and resulting macrophageactivation. Importantly, HA is recognized by scavenging intravitrealmacrophages as a native (non-immunogenic) because there is a highconcentration of HA naturally present in the vitreous humor. Thuscoating the TA drug particles with HA renders the injected Trivarisformulation non-antigenic, lowering the potential of the TA drugparticles to instigate an inflammatory response. Use of HA encapsulationas an ‘immunologic disguise’ is used in a similar fashion by somestreptococcus bacterial species to evade detection and phagocytosis bymacrophages and increasing the virulence of the organism. Importantly,the hydrogel formulation of Trivaris permits the TA particles to becomefree drug as the TA is solubilized (dissolves) in the vitreous, therebypermitting the solubilized TA to enter solution in the vitreous and thendiffuse or be actively transported to the retina to treat a retinaldisease or condition. The close proximity of the TA drug particles inthe Trivaris HA hydrogel allows for controlled and rapid agglomerationof the TA particles as the HA gradually diffuses over time out of thedepot formed upon intravitreal Trivaris injection.

An additional experiment was carried out to determine free TA particleexposure and pupillary obscuration in patients receiving eitherintravitreal Kenalog-40 or Trivaris. Thus a fundus photographyevaluation of patients was performed one hour after each is patient hadreceived an intravitreal injection of 4 mg of either Kenalog-40 (n=4) orTrivaris (n=3). A 48 μL (50 mg) injection of the Example 98% formulation(Trivaris 8%) provided the 4 mg of TA. Note that about 100 μL of theKenalog-40 was required to provide 4 mg of TA. The required greater(double) volume of Kenalog-40 to obtain the same amount of injected TAcan by itself cause deleterious effects (such as acute elevation ofintraocular pressure leading to central retnal artery occlusion) due tothe limited normal intravitreal volume. As shown by Table 7 it wasdetermined that about 83% of the TA particles were floating free in thevitreous after the Kenalog injections, whereas only about 6% of the TAparticles were free floating in the patients injected with Trivaris.Significantly, therefore about 84% of the Trivaris TA particles wereupon intravitreal injection embedded within the HA. Additionally, thepupil was obscured with drug particles in a mean of 29.8% of thepatients who received Kenalog, versus only a 1.7% pupil obscuration byTA particles in the patients who had received Trivaris.

Hence, Trivaris has minimal free TA drug particle exposure and pupilobscuration, compared with Kenalog, following intravitreal injection.

The low numbers of drug particles in an unbound state followinginjection of Trivaris can be expected to reduce activation of scavengingmacrophages compared with other TA suspensions, such as Kenalog-40,where the majority of the TA particles are upon intravitreal injectionexposed to macrophages and inflammatory consequences can then ensue. Theeffectiveness of the Trivaris formulation to reduce the inflammatorypotential has been observed in recent clinical trials. In over 1000patients in phase 3 clinical trials that have received injections ofTrivaris formulation, some multiple times, there have been no reportedcases of sterile endophthalmitis. The consolidation of the drugparticles in the Trivaris HA hydrogel, with a clear view through thepupillary axis, also enables immediate recovery of vision afterinjection & enables PDT, thermal laser and diagnostic procedures to beperformed.

A further experiment was carried out to examine the stability of the TAparticles in Trivaris. We determined that the TA drug particles in theHA hydrogel suspension of is Trivaris were remarkably stable, withminimal crystal agglomeration or degradation during extended storage.Thus, 0.5 mL glass syringes were filled with 0.2 mL of the Example 9formulation. The filled syringes were stored horizontally at 25° C. in60% relative humidity. Upon syringe filling (time zero), at 5 weeks, at6 weeks and after three months of storage, TA particle size wasdetermined using laser light scattering with Horiba LA 300 instrument,after dilution of a Trivaris sample in distilled water just prior to thelight scattering analysis. 90th percentile of volume-weighted sizedistribution data from three different lots showed that at time zero 90%of the TA particles had a diameter of 11 microns or less, at +5 weeksand at +6 weeks 90% of the TA particles still had a diameter of about 11microns or less. Finally at +3 months 90% of the TA particles still hada diameter of about 13 microns or less. These results mean that evenwith prolonged storage the TA particles remain suspended in the HA andundergo neither substantial agglomeration or degradation. Hence, evenafter prolonged storage Trivaris retains its syringability withoutneedle occlusion.

In addition to limiting particle exposure, the HA of Trivaris hasadditional inherent anti-inflammatory properties. Hyaluronic acidinhibits movement of macrophages, down regulates the production ofproinflammatory cytokines and chemokines in models and human diseases,scavenges oxygen free radicals, and inhibits matrix metalloproteinases.Trivaris can include additional features to minimize an inflammatoryreaction upon intravitreal injection, such as preparing Trivaris to havea pH between 6 and 7 range, and strict endotoxin and extraneous particlecontrol.

Furthermore, the uniform population of micronized TA particles inTrivaris (see FIG. 7) provides a predictable ocular TA releasepharmacokinetics with increased TA vitreous half-life.

The Example 8 and 9 Trivaris formulations can also be used as aninjectable pharmaceutical composition to treat various articular (jointsand spine) pathologies while at the same time reducing the potential foroccurrence of post-injection inflammation (crystal synovitis).

In summary, the Trivaris formulation creates a physical barrier to freemovement of drug particles to reduce the potential for particleexposure, macrophage activation, and the potential for sterileendophthalmitis. The consolidation of the TA drug particles in the HAhydrogel enables immediate recovery of vision after injection & enablesPDT, thermal laser and diagnostic procedures to be performed.Incorporating a uniform population of micronized TA particles in theformulation facilitates management by macrophages when outside of thedrug depot, but also leads to predictable ocular pharmacokinetics withan increased vitreous half-life. Trivaris is supplied in pre-loadedsyringes with little or no endotoxin and extraneous particle content, tothereby further limit post-injection inflammation. Trivaris does notcontain benzyl alcohol or any other preservatives thereby reducingtoxicity to retinal cells. TABLE 7 Photographic evaluation in patientsfollowing an intravitreal injection of Kenalog-40 or Trivaris 8% FreePosterior particles Consolidated PoleView Pupil Subject Kenalog-40Trivaris exposed % depot % obscuration* Obscuration** 1 X 80 20  2+ 10 2X 95 5  1+ 30 3 X 5 95 0 0 4 X 10 90 0 0 5 X 75 25 0 4 6 X 3 97 0 5 7 X80 20  3+ 75 TOTALS Kenalog 4 82.5 17.5  +1.5 29.8 Mean (SD) (8.7) (8.7)  (1.29) (32.1) Trivaris Mean 3 6.0 94.0 0 1.7 (SD) (3.6) (3.6) (2.9)*graded as Vitreous Haze (SUN Criteria) 0 through 4+**grade as % of pupillary area (dilated) obscured by drug as measuredwith the red reflex photo

While this invention has been described with respect to various specificexamples and embodiments, it is to be understood that the invention isnot limited thereto. For example, the corticosteroid formulations setforth herein can be used to treat conditions including articularpathologies, such as rheumatoid and osteoarthritis, and spinalconditions, such as facet arthritis, and the treatment of chronic painby epidural or spinal root injections of a formulation such as aTrivaris formulation

Additionally, although preferably the polymeric hyaluronate in Trivarisis a non-cross linked hyaluronate (so as to obtain, upon application offorce to the plunger of the syringe used to administer Trivaris, a highshear rate and hence relative ease of injection of Trivaris through a27-33 gauge needle), the hyaluronate can alternately be is a crosslinked hyaluronate (to form a true hydrogel therefore) with asignificantly lower viscosity (i.e. with a viscosity of about 5,000 cpsat a shear rate of about 0.1/second at about 25° C.). Such across-linked hyaluronate can have the same or similar excellentcorticosteroid suspension property of Trivaris, and have the additionaladvantage of longer residency (i.e. biodegradable at a slower rate) ofthe hyaluronate in the vitreous, with resulting prolonged nominalimmunogenicity of such a cross-linked hyaluronate formulation in thevitreous, due to a longer period of intravitreal (or intraocular)retention of the corticosteroid particles in the polymeric matrix of thecross-linked hyaluronate.

Furthermore, besides hyaluronate other cross-linked polymers can beused, such as for example a polycarbophil.

All references, articles, publications, patents and applications setforth above are incorporated herein by reference in their entireties.

1. A pharmaceutical composition for treating a posterior ocularcondition, the pharmaceutical composition comprising: (a) a plurality ofcorticosteroid particles mixed with; (b) a viscous polymer, wherein thepharmaceutical composition has a viscosity of between about 130,000 cpsand about 300,000 cps at a shear rate of about 0.1/second at about 25°C., and the pharmaceutical composition can be injected into the vitreousof a human eye through a 25 to 33 gauge needle.
 2. The pharmaceuticalcomposition of claim 1, wherein the corticosteroid particles have asubstantially uniform diameter.
 3. The pharmaceutical composition ofclaim 1, wherein substantially all the corticosteroid particles areembedded within the viscous polymer.
 4. The pharmaceutical compositionof claim 1, wherein the corticosteroid is a triamcinolone.
 5. Thepharmaceutical composition of claim 1, wherein the viscous polymer is apolymeric hyaluronate or a polymeric hyaluronic acid.
 6. Apharmaceutical composition for treating a posterior ocular condition,the composition comprising: (a) a plurality of triamcinolone particleswith a substantially uniform diameter, and; (b) a viscous polymerichyaluronate or polymeric hyaluronic acid, wherein the pharmaceuticalcomposition has a viscosity of between about 130,000 cps and about300,000 cps at a shear rate of about 0.1/second at about 25° C. and canbe injected into the vitreous of a human eye through a 25 to 33 gaugeneedle, wherein the triamcinolone particles are mixed with the viscouspolymer substantially all the corticosteroid particles are embeddedwithin and coated by the viscous polymeric hyaluronate or a polymerichyaluronic acid.
 7. A method for treating a posterior ocular condition,the method comprising the step of injecting into the vitreous of apatient's eye with a posterior ocular condition a viscous pharmaceuticalcomposition comprising a plurality of corticosteroid particles mixedinto a viscous polymeric matrix, wherein the pharmaceutical compositionhas a viscosity of between about 130,000 cps and about 300,000 cps at ashear rate of about 0.1/second at about 25° C., such that about one hourafter the intravitreal injection only about 10% or less of thecorticosteroid particles are present in the vitreous free of thepolymeric matrix.
 8. The method of claim 7, wherein about one hour afterthe intravitreal injection only about 5% or less of the corticosteroidparticles are present in the vitreous free of the is polymeric matrix.9. The method of claim 7, wherein about one hour after the intravitrealinjection only about 3% or less of the corticosteroid particles arepresent in the vitreous free of the polymeric matrix.
 10. A process formaking an intraocular pharmaceutical composition, the method comprisingthe step of mixing an aqueous suspension of a plurality ofcorticosteroid particles and an aqueous solution of a viscous polymericmatrix, so that the resulting pharmaceutical composition has a viscosityof between about 130,000 cps and about 300,000 cps at a shear rate ofabout 0.1/second at about 25° C.
 11. The process of claim 10, whereinthe corticosteroid particles have a median particle size of betweenabout 4 microns and about 5 microns.
 12. The process of claim 10,wherein the corticosteroid particles have a stable diameter for at leastthree months after the pharmaceutical has been made and stored for threemonths in a syringe placed horizontally at about 25° C. at about 60%relative humidity.
 13. The pharmaceutical composition made by the methodof claim
 10. 14. A pharmaceutical composition for treating an articularpathology, the pharmaceutical composition comprising: (a) a plurality ofcorticosteroid particles mixed with; (b) a viscous polymer, wherein thepharmaceutical composition has a viscosity of between about 130,000 cpsand about 300,000 cps at a shear rate of about 0.1/second at about 25°C.,
 15. A method for treating an articular pathology, the methodcomprising the step of is injecting into a joint of a patient with anarticular pathology a viscous pharmaceutical composition comprising aplurality of corticosteroid particles mixed into a viscous polymericmatrix, wherein the pharmaceutical composition has a viscosity ofbetween about 130,000 cps and about 300,000 cps at a shear rate of about0.1/second at about 25° C.